Information Collection

Formative Evaluation of Zika Prevention Kits for Pregnant Women in Puerto Rico

IC 220174 under ICR 201503-0920-011 · OMB 0920-1071.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1071 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Formative Evaluation of Zika Prevention Kits for Pregnant Women in Puerto Rico	Form and Instruction
Intercept Interview of Pregnant Women in Puerto Rico ZP Kit_Intercept Interview Guide_APPROVED BY PRDOH.DOCX	Form and Instruction
Fast_Track_GenIC_Request for ZPK feeedback from pregnant women.DRAFT.DOCX Fast Track GenIC Request Zika Intercept Interview	IC Document

IC Title:

Formative Evaluation of Zika Prevention Kits for Pregnant Women in Puerto Rico

Agency IC Tracking Number:

16QG

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	Intercept Interview of Pregnant Women in Puerto Rico	ZP Kit_Intercept Interview Guide_APPROVED BY PRDOH.DOCX	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 70

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	18	18
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track GenIC Request Zika Intercept Interview	Fast_Track_GenIC_Request for ZPK feeedback from pregnant women.DRAFT.DOCX	02/19/2016

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