Zika Family Survey: In-Depth Interviews with Women Affected by Zika Virus

Form Approved

OMB No. 0920-1154

Exp. Date: 01/21/2020

[State/local Health Dept.]

[January 2018]

Dear [enter name]:

We are asking for your help to improve resources for families who have been affected by the Zika virus.

We are interviewing mothers who had the Zika virus during pregnancy to better know what types of medical and support services their babies are receiving. By telling your story, you can help other families affected by Zika.

We’ve contacted you in the past because you had Zika during your pregnancy. In the next few days, we will call you on the phone to make sure you got this information and answer any questions you may have about the study. You then can decide if you want to do the interview.

The interview will take one hour. You can choose if you want to do the interview.

If you take part in the interview, you will get a $40 VISA gift afterward to thank you for your time. We have also included $2.00 to pay for any phone charges when you do the interview.

Want to take part? To schedule a time for the interview, you can do one of these things:

• Call: 866-590-7466

• Email: [email protected]

• Return the postcard

RTI International is coordinating these interviews for the Centers for Disease Control and Prevention (CDC) and the March of Dimes Foundation. If you have questions about the study, you can call the project director, Dr. Linda Squiers, at 1-800-334-8571, ext. 25128 (toll free). If you have any questions about your rights as a participant, you can call RTI’s Office of Research Protection toll-free at 1-866-214-2043.

Sincerely,

[Health Department Contact]

Public reporting burden of this collection of information is estimated to average 5 minutes, 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-1154).