Contraceptive Assessment Questionnaire

Emergency Zika Package IV: Assessment of Contraceptive Use and Needs, Puerto Rico, 2016

Documents and Forms

Document Name Document Type
Contraceptive Assessment Questionnaire Form and Instruction
CONTRACEPTIVE ASSESSMENT FOR PUERTO RICO DURING ZIKA (CA Contraceptive Assessmentl 6-14-16.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Contraceptive Assessment Questionnaire	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	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: 2,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	625	625
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.