Demographic/Clinical Data for Sites Conducting Core Surveillance

Gonococcal Isolate Surveillance Project

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0307 can be found here:

Documents and Forms

Document Name Document Type
Demographic/Clinical Data for Sites Conducting Core Surveillance Form
Att 7_Data coding guide.docx Instruction
Core Demographic/Clinical Data Att 3a1_core clinic data.pptx Form

Information Collection (IC) Details

IC Title:	Demographic/Clinical Data for Sites Conducting Core Surveillance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	n/a	Core Demographic/Clinical Data	Att 3a1_core clinic data.pptx		Yes	Yes	Fillable Fileable
Instruction			Att 7_Data coding guide.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136: Epidemiologic Studies and Surveillance of Disease Problems. HHS/CDC”	FR Citation: 57 FR 62812

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,800	-2,400	7,200
Annual IC Time Burden (Hours)	880	-440	1,320
Annual IC Cost Burden (Dollars)	16,966	16,966	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.