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

Information Collection (IC) Details

View Information Collection (IC)

Online Survey - 12 month Follow-Up - Patients 18 years or older
 
No New
 
Voluntary
 

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

Health Public Health Monitoring

09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems   57 FR 62812

534 0
   
Individuals or Households
 
   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

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

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