Information Collection

Maternal and Child Health Zika Capacity Assessment

IC 227385 under ICR 201412-0920-011 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.