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30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey
Assessment of a Preventive Service Program in the Context of a Zika Virus Outbreak in Puerto Rico
OMB: 0920-1241
IC ID: 232335
OMB.report
HHS/CDC
OMB 0920-1241
ICR 201902-0920-017
IC 232335
( )
Documents and Forms
Document Name
Document Type
30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey
Form and Instruction
Att H-3 Patient Survey 30 mo version B (Eng and Span).docx
Other-Word version of survey content
Screenshots of the 30-month Follow-up Survey (Version B
Att H-6 Patient Survey 30 mo Ver B Screen Shots.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
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
n/a
Screenshots of the 30-month Follow-up Survey (Version B for Z-CAN patients who did not complete the 18-month Follow-up Survey)
Att H-6 Patient Survey 30 mo Ver B Screen Shots.pdf
Yes
Yes
Fillable Fileable
Other-Word version of survey content for reference/editing (English and Spanish)
Att H-3 Patient Survey 30 mo version B (Eng and Span).docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Disaster Management
Subfunction:
Emergency Response
Privacy Act System of Records
Title:
09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
220
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
220
0
0
0
0
220
Annual IC Time Burden (Hours)
37
0
0
0
0
37
Annual IC Cost Burden (Dollars)
266
0
0
0
0
266
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.