Maternal Health History Form

CDC Emergency Operations Center Zika Related Clinical Inquiries and Surveillance

Documents and Forms

Document Name Document Type
Maternal Health History Form Form and Instruction
Pregnancy and Zika Virus Disease Surveillance Form Att. E -- Maternal Health History Form 31MAR2016.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Maternal Health History Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

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	Pregnancy and Zika Virus Disease Surveillance Form	Att. E -- Maternal Health History Form 31MAR2016.doc	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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