Information Collection

Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016

IC 222590 under ICR 201604-0920-011 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016	Form and Instruction
Healthcare Professional Risk Assessment Questionnaire Data collection forms for HCP evaluation UT.docx	Form and Instruction
UT Zika Investigation TOR.pdf Letter of Invitation	IC Document
Burden Memo Email.msg Burden Memo Email	IC Document
1 GenIC Request Form - EEI Generic ICR_HCP_rev.docx GenIC Request - HCP	IC Document

IC Title:

Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016

Agency IC Tracking Number:

0920-1011

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	Healthcare Professional Risk Assessment Questionnaire	Data collection forms for HCP evaluation UT.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemic Investigation Case Records - SORN number 09-20-0113

FR Citation: 51 FR 42466

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

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	100	100
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation	UT Zika Investigation TOR.pdf	07/22/2016
Burden Memo Email	Burden Memo Email.msg	07/22/2016
GenIC Request - HCP	1 GenIC Request Form - EEI Generic ICR_HCP_rev.docx	07/22/2016

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