Assessment at Delivery Form

CDC Emergency Operations Center Zika Related Clinical Inquiries and Surveillance

Documents and Forms

Document Name Document Type
Assessment at Delivery Form Form and Instruction
Pregnancy and Zika virus disease surveillance form - Neo Att. F -- Assessment at Delivery Form 31MAR2016.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Assessment at Delivery Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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 - Neonate Assessment	Att. F -- Assessment at Delivery 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 - Epidemiological Studies and Surveillance of Disease Problems	FR Citation: 57 FR 82612

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

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	50	50
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.