Assessment of the Zika Care Connect Program

CDC/ATSDR Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1154 Assessment of the Zika Care Connect Program Form and Instruction
0920-1154 Invitation Email to access Survey - Health Care Professi Attachment 6_Email and Reminder Email - Survey of Healthcare Professiona....docx Form and Instruction
0920-1154 Reminder Invitation Email to access Survey - Health Care Attachment 6_Email and Reminder Email - Survey of Healthcare Professiona....docx Form and Instruction
0920-1154 Survey - Healthcare Professional Attachment 4_Information Collection Instrument - Survey of Healthcare Pr....docx Form and Instruction
0920-1154 Pop-Up Invitation to Survey - Website User Attachment 5_Information Collection Instrument - Survey of Website Users....docx Form and Instruction
0920-1154 Survey - Website User Attachment 5_Information Collection Instrument - Survey of Website Users....docx Form and Instruction
SSA_ZCC eval_ver2_clean.docx Supporting Statement A IC Document
SSB_ZCC evaluation_ver2_clean.docx Supporting Statement B IC Document
Attachment 3_ IRB determination Letter.pdf IRB Determination IC Document

Information Collection (IC) Details

IC Title:	Assessment of the Zika Care Connect Program	Agency IC Tracking Number:	0920-1154-18JN

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	0920-1154	Invitation Email to access Survey - Health Care Professional	Attachment 6_Email and Reminder Email - Survey of Healthcare Professiona....docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154	Reminder Invitation Email to access Survey - Health Care Professional	Attachment 6_Email and Reminder Email - Survey of Healthcare Professiona....docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154	Survey - Healthcare Professional	Attachment 4_Information Collection Instrument - Survey of Healthcare Pr....docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154	Pop-Up Invitation to Survey - Website User	Attachment 5_Information Collection Instrument - Survey of Website Users....docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154	Survey - Website User	Attachment 5_Information Collection Instrument - Survey of Website Users....docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,080	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	4,080	4,080
Annual IC Time Burden (Hours)	260	260
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	SSA_ZCC eval_ver2_clean.docx	12/26/2017
Supporting Statement B	SSB_ZCC evaluation_ver2_clean.docx	12/26/2017
IRB Determination	Attachment 3_ IRB determination Letter.pdf	12/26/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.