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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.