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Online Survey - 12 month Follow-Up - Patients 18 years or older
Monitoring & Evaluation for the Zika Contraception Access Network (Z-CAN)
OMB: 0920-1164
IC ID: 225613
OMB.report
HHS/CDC
OMB 0920-1164
ICR 201702-0920-003
IC 225613
( )
Documents and Forms
Document Name
Document Type
Online Survey - 12 month Follow-Up - Patients 18 years or older
Form and Instruction
Onsline Survey - Patient 18 yr 12-month Follow-Up Englis
Att R-3 Patient Survey_12 mo vB (Eng).docx
Form and Instruction
Onsline Survey - Patient 18 yr 12-month Follow-Up Spanis
Att R-4_Screen shots_Patient Survey_12 mo vB (Span).pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Online Survey - 12 month Follow-Up - Patients 18 years or older
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
Onsline Survey - Patient 18 yr 12-month Follow-Up English
Att R-3 Patient Survey_12 mo vB (Eng).docx
NA
Yes
Yes
Fillable Fileable
Form and Instruction
NA
Onsline Survey - Patient 18 yr 12-month Follow-Up Spanish/Screenshot
Att R-4_Screen shots_Patient Survey_12 mo vB (Span).pdf
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:
534
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
534
0
534
0
0
0
Annual IC Time Burden (Hours)
89
0
89
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.