SEVERE NEUROLOGIC ILLNESS Chart Abstraction Questionnaire

Zika Virus Associated Neurologic Illness Case Control Study in Puerto Rico

Documents and Forms

Document Name Document Type
SEVERE NEUROLOGIC ILLNESS Chart Abstraction Questionnaire Form and Instruction
Chart Abstraction Questionnaire for the Investigation of CaCo Chart Abstraction Questionnaire_Severe Neuro_4Oct.docx Form and Instruction

Information Collection (IC) Details

IC Title:	SEVERE NEUROLOGIC ILLNESS Chart Abstraction Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	Chart Abstraction Questionnaire for the Investigation of Severe Neurologic Illness in relation to Arboviral Infections	CaCo Chart Abstraction Questionnaire_Severe Neuro_4Oct.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
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.