Form 42 Zika Progress Report

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
ZIKA PROGRESS REPORT

FOR HRSA USE ONLY
Grant
Number

Current
reporting
period

1.       Zika Activities

Progress Report Tracking
Number

Percent

Cumulative
Total

1a.

Number of individuals who received assistance with education and counseling
regarding Zika

N/A

To be
calculated by
HRSA

1b.

Number of Zika diagnostic tests performed

N/A

To be
calculated by
HRSA

1c.

Number of positive Zika diagnostic tests

To be
calculated by
HRSA

To be
calculated by
HRSA

1d.

Number of patients with a visit for contraceptive management services

N/A

To be
calculated by
HRSA

2. Issues/Barriers (for the current reporting period only)
For the current reporting period, describe up to three major issues/barriers that you experienced while conducting Zika activities.

Required; up to 2500 characters (1 page)
3. Key Strategies and Successes (for the current reporting period only)
For the current reporting period, describe up to three strategies that contributed most to the success of your Zika activities.

Required; up to 2500 characters (1 page)
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0285. Public reporting burden for
this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing
data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers
Lane, Room 14N-39, Rockville, Maryland, 20857