Household Questionnaire

Assessment to Estimate the Effect of Community-Wide Vector Control Initiatives on Zika Virus Transmission in Puerto Rico, 2016

Documents and Forms

Document Name Document Type
Household Questionnaire Form and Instruction
Zika Investigation - Household Interview Form ENGLISH Att G - Household questionnaire.docx Form and Instruction
Zika Investigation - Household Interview Form SPANISH Att G - Household Questionnaire SPANISH.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Household Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	Zika Investigation - Household Interview Form ENGLISH	Att G - Household questionnaire.docx	NA	No		Paper Only
Form and Instruction	NA	Zika Investigation - Household Interview Form SPANISH	Att G - Household Questionnaire SPANISH.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0113 Epidemic Investigation Case Records Systems Notice	FR Citation: 51 FR 42466

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	60	60
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.