Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Assessment of STD Service Needs and Provisions
Agency IC Tracking Number:
0920-0840-18ANV
IC Status:
New
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
Patient Questionnaire
Att 3a1 Patient Questioannaire.docx
No
Paper Only
Form
none
Administrative Questionnaire
Att 3b Administrative Questionnaire.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
5,025
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
5,025
0
5,025
0
0
0
Annual IC Time Burden (Hours)
421
0
421
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement A
SSA 8.8.18.doc
08/09/2018
Supporting Statement B
SSB-2.doc
08/09/2018
Consent/Assent
Att 4 Consent_Assent Form.docx
08/09/2018
Recruitment Letter - Prior Participant
Att 5b prior participant-letterhead.pdf
08/09/2018
Recruitment Letter - New Participant
Att 5a new participant-letterhead.pdf
08/09/2018
Instruction Script
Att 6 Visit Script.docx
08/09/2018
PIA
Att 7 Privacy Impact Assessment_PIA.pdf
08/09/2018
Project Determination
Project-Determination-and-Approval-Form.pdf
08/09/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.