PR Zika Investigation –Refusal Demographics Form

Form Approved

OMB No. 0920-1137

Expires 03/31/2017

PR Zika Investigation –Refusal Demographics Form

Cluster (e.g., B-1): ____-____ Date: _____/_____/__________

MM DD YYYY

Investigation Team: ____________

In the homes that refuse to participate, please record the number of people that live there in these 6 categories.

House ID	Female (years)			Male (years)
	<21	21 – 64	65+	<21	21 – 64	65+



Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-1137/).