Information Collection

Contraceptive Assessment Screen

IC 221549 under ICR 201606-0920-020 · OMB 0920-1114.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Contraceptive Assessment Screen	Form and Instruction
CONTRACEPTIVE ASSESSMENT FOR PUERTO RICO DURING ZIKA (CA Contraceptive Assessmentl 6-14-16.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	CONTRACEPTIVE ASSESSMENT FOR PUERTO RICO DURING ZIKA (CAPRZ) QUESTIONNAIRE	Contraceptive Assessmentl 6-14-16.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: 09-20-0113 Epidemic Investigation Case Records

FR Citation: 51 FR 42466

Number of Respondents: 12,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	12,000	12,000
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.