Information Collection

Form 1 - Demographic/Clinical Data

IC 6747 under ICR 201307-0920-009 · OMB 0920-0307.

⚠️ Notice: This information collection may be referencing outdated material.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
Form CDC73.60A Form 1 - Demographic/Clinical Data Form
CDC73.60A Form 1: Demographic/Clinical Data Att 3a_Demo_ClinicData_FINAL.pdf Form
Att 3_Proposed Changes_FINAL.docx Att 3_Proposed Changes_FINAL IC Document
Att 4_Screenshots_FINAL.doc Att 4_Screenshots_FINAL IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form 1 - Demographic/Clinical Data	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	CDC73.60A	Form 1: Demographic/Clinical Data	Att 3a_Demo_ClinicData_FINAL.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7,200	7,200
Annual IC Time Burden (Hours)	1,320	1,320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 3_Proposed Changes_FINAL	Att 3_Proposed Changes_FINAL.docx	07/18/2013
Att 4_Screenshots_FINAL	Att 4_Screenshots_FINAL.doc	07/18/2013

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