Information Collection

Survey of non-Title X Clinic Providers

IC 203902 under ICR 201810-0920-003 · OMB 0920-0969.

Documents and Forms

Document Name Document Type
Survey of non-Title X Clinic Providers Form
Survey of Health Care Providers about Family Planning At Att E-1 2018-2019 Survey of Health Care Providers about Family Planning.doc Form
Survey of Health Care Providers about Family Planning At Att E-2 Screen shots of provider survey.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey of non-Title X Clinic Providers	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	none	Survey of Health Care Providers about Family Planning Attitudes and Practices	Att E-1 2018-2019 Survey of Health Care Providers about Family Planning.doc		Yes	Yes	Fillable Fileable
Form	none	Survey of Health Care Providers about Family Planning Attitude and Practices - screenshots	Att E-2 Screen shots of provider survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 20 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	8,840	8,840

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.