Maternal and Child Health Zika Capacity Assessment

Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Document Name Document Type
Maternal and Child Health Zika Capacity Assessment Form and Instruction
Local Health Department MCH Zika Capacity Assessment Attachment B - Capacity Assessment (Web Version).docx Form and Instruction
MCH-ZIKA-SSA.docx Supporting Statement A IC Document
MCH-ZIKA-SSB.docx Supporting Statement B IC Document
Attachment A - Respondent Breakdown.pdf Respondent Breakdown IC Document
Attachment D - Notification Email.docx Notification Email IC Document
Attachment E - Reminder Email.docx Reminder Email IC Document
Attachment F - Extension Email.docx Extension Email IC Document

Information Collection (IC) Details

IC Title:	Maternal and Child Health Zika Capacity Assessment	Agency IC Tracking Number:	0920-0879-17UAO

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	Local Health Department MCH Zika Capacity Assessment	Attachment B - Capacity Assessment (Web Version).docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 690	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	690	690
Annual IC Time Burden (Hours)	104	104
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	MCH-ZIKA-SSA.docx	07/06/2017
Supporting Statement B	MCH-ZIKA-SSB.docx	07/06/2017
Respondent Breakdown	Attachment A - Respondent Breakdown.pdf	07/06/2017
Notification Email	Attachment D - Notification Email.docx	07/06/2017
Reminder Email	Attachment E - Reminder Email.docx	07/06/2017
Extension Email	Attachment F - Extension Email.docx	07/06/2017

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