Baseline and Follow-Up Questionnaire - Symptomatic

Zika virus persistence in body fluids of patients with Zika virus infection in Puerto Rico (ZIPER Study)

Documents and Forms

Document Name Document Type
Baseline and Follow-Up Questionnaire - Symptomatic Form and Instruction
Baseline and Follow-Up Questionnaire - English 29SEP2016 Att H - Baseline and follow-up questionnaire.docx Form and Instruction
Baseline and Follow-Up Questionnaire - Spanish 29SEP2016 Att H - Baseline and follow-up questionnaire ESP.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Baseline and Follow-Up Questionnaire - Symptomatic	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	Baseline and Follow-Up Questionnaire - English 29SEP2016	Att H - Baseline and follow-up questionnaire.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Baseline and Follow-Up Questionnaire - Spanish 29SEP2016	Att H - Baseline and follow-up questionnaire ESP.docx	NA	Yes	Yes	Fillable Fileable

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: 200	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-1,600	1,600
Annual IC Time Burden (Hours)	-267	267
Annual IC Cost Burden (Dollars)	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.