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

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⚠️ Notice: This information collection may be referencing outdated material.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
Attachment A Intro Letter to Participants.docx Instruction
Attachment C Follow Up Script and_FAQs.docx Instruction
0920-1154 IN-DEPTH INTERVIEWS WITH WOMEN AFFECTED BY THE ZIKA VIRU Attachment E Interview Guide.docx Form and Instruction
Attachment D Consent Form.docx Interview Consent Form IC Document
Attachment B Letter to Doctors.docx Letter to Doctor IC Document
Attachment F IRB Approval STUDY00020014.pdf IRB Approval - RTI IC Document
Support Statement A_Zika Family Survey.doc Supporting Statement A IC Document
Support Statement B_ Zika Family Survey.docx Supporting Statement B IC Document

Information Collection (IC) Details

IC Title:	Zika Family Survey: In-Depth Interviews with Women Affected by Zika Virus	Agency IC Tracking Number:	0920-1154-18WT

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Electronic Capability
Instruction			Attachment A Intro Letter to Participants.docx	NA	No	Paper Only
Instruction			Attachment C Follow Up Script and_FAQs.docx	NA	No	Paper Only
Form and Instruction	0920-1154	IN-DEPTH INTERVIEWS WITH WOMEN AFFECTED BY THE ZIKA VIRUS - INTERVIEW GUIDE	Attachment E Interview Guide.docx	NA	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 260	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	260	260
Annual IC Time Burden (Hours)	85	85
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Interview Consent Form	Attachment D Consent Form.docx	04/03/2018
Letter to Doctor	Attachment B Letter to Doctors.docx	04/03/2018
IRB Approval - RTI	Attachment F IRB Approval STUDY00020014.pdf	04/03/2018
Supporting Statement A	Support Statement A_Zika Family Survey.doc	04/03/2018
Supporting Statement B	Support Statement B_ Zika Family Survey.docx	04/03/2018

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