Information Collection

Domestic Readiness Initiative on Zika Virus Disease

IC 225268 under ICR 201502-0920-001 · OMB 0920-0572.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0572 Domestic Readiness Initiative on Zika Virus Disease Form and Instruction
0920-0572 Attachment 4 - Provider Screener_1_13 Attachment 4 - Provider Screener_1_13.docx Form and Instruction
0920-0572 Attachment 5 - Provider Survey_1_13 Attachment 5 - Provider Survey_1_13.docx Form and Instruction
0920-0572 Attatchment 6 - FGPRScreener_1_13 Attatchment 6 - FGPRScreener_1_13.docx Form and Instruction
0920-0572 Attachment 7 - FGPRGuide_1-13-17 Attachment 7 - FGPRGuide_1-13-17.docx Form and Instruction
0920-0572 ttachment2 - Consumer Screener for IDICONUS_1_13 ttachment2 - Consumer Screener for IDICONUS_1_13.docx Form and Instruction
0920-0572 Attachment 3 consumer IDI Guide_l1_13 Attachment 3 consumer IDI Guide_l1_13.docx Form and Instruction
HMTS Expedited Review Form Domestic Readiness - Zika - final .pdf HMTS Expedited Review Form Domestic Readiness - Zika - final IC Document
Attachment 9 - Justification for Remuneration_1-7.docx Attachment 9 - Justification for Remuneration_1-7 IC Document
Attachment A - Puerto Rico Campaign ImagesScreenShots.docx Attachment A - Puerto Rico Campaign ImagesScreenShots IC Document
Attachment B -Spanish_Stop Zika Campaign Testing (SP) 1-13-2017.pdf Attachment B -Spanish_Stop Zika Campaign Testing (SP) 1-13-2017 IC Document
Attachment C - Consent Language for Provider + Consumer IC.docx Attachment C - Consent Language for Provider + Consumer IC IC Document
Attachment D_ScreenShot for HCP SurveysCONUSandPR.docx Attachment D_ScreenShot for HCP SurveysCONUSandPR IC Document
Attachment E - ScreenShot of Consumer Materials1_13.docx Attachment E - ScreenShot of Consumer Materials1_13 IC Document
Atttachment 8 - FGPRSupplemental Handout_1-13-17.docx Atttachment 8 - FGPRSupplemental Handout_1-13-17 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Domestic Readiness Initiative on Zika Virus Disease	Agency IC Tracking Number:	17MZ

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0572	Attachment 4 - Provider Screener_1_13	Attachment 4 - Provider Screener_1_13.docx	Yes	No	Fillable Printable
Form and Instruction	0920-0572	Attachment 5 - Provider Survey_1_13	Attachment 5 - Provider Survey_1_13.docx	Yes	No	Fillable Printable
Form and Instruction	0920-0572	Attatchment 6 - FGPRScreener_1_13	Attatchment 6 - FGPRScreener_1_13.docx	No		Fillable Printable
Form and Instruction	0920-0572	Attachment 7 - FGPRGuide_1-13-17	Attachment 7 - FGPRGuide_1-13-17.docx	No		Fillable Printable
Form and Instruction	0920-0572	ttachment2 - Consumer Screener for IDICONUS_1_13	ttachment2 - Consumer Screener for IDICONUS_1_13.docx	No		Fillable Printable
Form and Instruction	0920-0572	Attachment 3 consumer IDI Guide_l1_13	Attachment 3 consumer IDI Guide_l1_13.docx	No		Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 575	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 60 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	575	575
Annual IC Time Burden (Hours)	342	342
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HMTS Expedited Review Form Domestic Readiness - Zika - final	HMTS Expedited Review Form Domestic Readiness - Zika - final .pdf	01/20/2017
Attachment 9 - Justification for Remuneration_1-7	Attachment 9 - Justification for Remuneration_1-7.docx	01/20/2017
Attachment A - Puerto Rico Campaign ImagesScreenShots	Attachment A - Puerto Rico Campaign ImagesScreenShots.docx	01/20/2017
Attachment B -Spanish_Stop Zika Campaign Testing (SP) 1-13-2017	Attachment B -Spanish_Stop Zika Campaign Testing (SP) 1-13-2017.pdf	01/20/2017
Attachment C - Consent Language for Provider + Consumer IC	Attachment C - Consent Language for Provider + Consumer IC.docx	01/20/2017
Attachment D_ScreenShot for HCP SurveysCONUSandPR	Attachment D_ScreenShot for HCP SurveysCONUSandPR.docx	01/20/2017
Attachment E - ScreenShot of Consumer Materials1_13	Attachment E - ScreenShot of Consumer Materials1_13.docx	01/20/2017
Atttachment 8 - FGPRSupplemental Handout_1-13-17	Atttachment 8 - FGPRSupplemental Handout_1-13-17.docx	01/20/2017

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