Viral Shedding Eligibility Form

Form Approved

OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX

Attachment G. Eligibility Form

1. Are you a resident of Puerto Rico?

___ Yes ___ No

2. Have you previously participated in the ZIKV persistence study?

___ Yes ___ No

3. For asymptomatic contacts only: Have you had fever, rash, red eye or joint pain since November 1, 2015?

___ Yes ___ No

4. For asymptomatic contacts only: Do you have a study coupon?

___ Yes ___ No

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX