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Maternal Health History Form
CDC Emergency Operations Center Zika Related Clinical Inquiries and Surveillance
OMB: 0920-1101
IC ID: 220142
OMB.report
HHS/CDC
OMB 0920-1101
ICR 201602-0920-005
IC 220142
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1101 can be found here:
2016-04-01 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Maternal Health History Form
Form and Instruction
Pregnancy and Zika Virus Disease Surveillance Form
Att E -- Maternal Health History Form 17FEB2016.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Maternal Health History Form
Agency IC Tracking Number:
Is this a Common Form?
No
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 and Instruction
NA
Pregnancy and Zika Virus Disease Surveillance Form
Att E -- Maternal Health History Form 17FEB2016.docx
NA
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
100
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 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
500
0
500
0
0
0
Annual IC Time Burden (Hours)
250
0
250
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
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.