SEVERE NEUROLOGIC ILLNESS Questionnaire for Case/Control

Zika Virus Associated Neurologic Illness Case Control Study in Puerto Rico

Documents and Forms

Document Name Document Type
SEVERE NEUROLOGIC ILLNESS Questionnaire for Case/Control Form and Instruction
Case-Control Study Questionnaire for the Investigation o PR Severe Neuro Illness_CaCo Questionnaire_English_4Oct.doc Form and Instruction

Information Collection (IC) Details

IC Title:	SEVERE NEUROLOGIC ILLNESS Questionnaire for Case/Control	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	Case-Control Study Questionnaire for the Investigation of Severe Neurologic Illness in relation to Arboviral Infections	PR Severe Neuro Illness_CaCo Questionnaire_English_4Oct.doc	NA	No		Paper Only

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: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	30	30
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.