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Hospital-based Survey for Mothers
Zika Postpartum Emergency Response Survey (ZPER) - Puerto Rico 2017
OMB: 0920-1183
IC ID: 226837
OMB.report
HHS/CDC
OMB 0920-1183
ICR 201704-0920-006
IC 226837
( )
Documents and Forms
Document Name
Document Type
Hospital-based Survey for Mothers
Form and Instruction
ZPER Maternal Hospital-based Questionnaire - English
Att 7a Hospital-based Survey for Mothers _English.doc
Form and Instruction
ZPER Maternal Hospital-based Questionnaire - Spanish
Att 7b Hospital-based Survey for Mothers_Spanish.doc.docx
Form and Instruction
Maternal Hospital-based Questionnaire - English Screensh
Att 7c Hospital-based Survey for Mothers_English_tablet screenshots.pdf
Form and Instruction
ZPER Maternal Hospital-based Questionnaire - Spanish Scr
Att 7d Hospital-based Survey for Mothers_Spanish_table screenshots.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Hospital-based Survey for Mothers
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
ZPER Maternal Hospital-based Questionnaire - Spanish
Att 7b Hospital-based Survey for Mothers_Spanish.doc.docx
NA
Yes
Yes
Fillable Fileable
Form and Instruction
NA
Maternal Hospital-based Questionnaire - English Screenshot
Att 7c Hospital-based Survey for Mothers_English_tablet screenshots.pdf
NA
Yes
Yes
Fillable Fileable
Form and Instruction
NA
ZPER Maternal Hospital-based Questionnaire - English
Att 7a Hospital-based Survey for Mothers _English.doc
NA
Yes
Yes
Fillable Fileable
Form and Instruction
NA
ZPER Maternal Hospital-based Questionnaire - Spanish Screenshot
Att 7d Hospital-based Survey for Mothers_Spanish_table screenshots.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:
3,120
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
10 %
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
3,120
0
3,120
0
0
0
Annual IC Time Burden (Hours)
1,300
0
1,300
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.