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Contraceptive Assessment Screen
Emergency Zika Package IV: Assessment of Contraceptive Use and Needs, Puerto Rico, 2016
OMB: 0920-1114
IC ID: 221549
OMB.report
HHS/CDC
OMB 0920-1114
ICR 201606-0920-020
IC 221549
( )
Documents and Forms
Document Name
Document Type
Contraceptive Assessment Screen
Form and Instruction
CONTRACEPTIVE ASSESSMENT FOR PUERTO RICO DURING ZIKA (CA
Contraceptive Assessmentl 6-14-16.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Contraceptive Assessment Screen
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 and Instruction
NA
CONTRACEPTIVE ASSESSMENT FOR PUERTO RICO DURING ZIKA (CAPRZ) QUESTIONNAIRE
Contraceptive Assessmentl 6-14-16.docx
NA
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
09-20-0113 Epidemic Investigation Case Records
FR Citation:
51 FR 42466
Number of Respondents:
12,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
12,000
0
0
0
0
12,000
Annual IC Time Burden (Hours)
200
0
0
0
0
200
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.