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Clinic Visit Record For Family Planning Services
CLINIC VISIT RECORD FOR FAMILY PLANNING SERVICES
OMB: 0937-0005
IC ID: 112189
OMB.report
HHS/OASH
OMB 0937-0005
ICR 197712-0937-002
IC 112189
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0005 can be found here:
1979-10-23 - No material or nonsubstantive change to a currently approved collection
1979-10-02 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
CLINIC VISIT RECORD FOR FAMILY PLANNING SERVICES
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
HRA-192-1, 2
No
No
Form
3, 4, 5, 6,
No
No
Form
7, 8, 9, 10,
No
No
Form
11, 12, 13,
No
No
Form
& 14
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
300,000
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
300,000
0
0
0
0
300,000
Annual IC Time Burden (Hours)
48,000
0
0
-27,000
0
75,000
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.