Information Collection

Formative Research To Develop Zika Tools For Healthcare Providers

IC 231333 under ICR 201610-0920-009 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1154 ACOG Zika Virus Survey FORMATIVE RESEARCH TO DEVELOP ZIKA TOOLS FOR HEALTHCARE PROVIDERS	Form
Form 0920-1154 Focus Group Recruitment Screen FORMATIVE RESEARCH TO DEVELOP ZIKA TOOLS FOR HEALTHCARE PROVIDERS	Form and Instruction
Form 0920-1154 ACOG Evaluation of Local Health Department Initiative FORMATIVE RESEARCH TO DEVELOP ZIKA TOOLS FOR HEALTHCARE PROVIDERS	Form and Instruction
Attachment F - Focus Group Discussion Guide.docx	Other-Focus Group Discussion Guide -
0920-1154 ACOG Zika Virus Survey Attachment A - Survey of Ob-Gyns Mailed.docx	Form
0920-1154 Focus Group Recruitment Screen Attachment G - Focus Group Recruitment Screener.docx	Form and Instruction
0920-1154 ACOG Evaluation of Local Health Department Initiative Attachment I - LHD Survey.docx	Form and Instruction
Attachment B - Survey of Ob-Gyns Email Invitation.docx Email Invitation (OB-GYN)	IC Document
Attachment C - Survey of Ob-Gyns Email Reminders.docx Email Reminder (OB-GYN)	IC Document
Attachment D - Survey of Ob-Gyns Mailing Cover Letter.docx Cover Letter Invitation	IC Document
Attachment E - Survey of Ob-Gyns IRB Approval.pdf IRB Approval	IC Document
Attachment J - LHD Survey Email Invitation.docx Email Invitation (Local Health Department)	IC Document
Attachment K - LHD Survey Email Reminders.DOCX Email Reminder	IC Document
Attachment L - LHD Survey IRB Approval.docx IRB Approval (Local Health Department)	IC Document
Attachment H - Focus Group IRB Approval.docx ACOG Focus Group IRB Approval	IC Document
Revised Supporting Statement A 04MAY2018.docx Supporting Statement A	IC Document
Revised Supporting Statement B 04MAY2018.docx Supporting Statement B	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

FORMATIVE RESEARCH TO DEVELOP ZIKA TOOLS FOR HEALTHCARE PROVIDERS

Agency IC Tracking Number:

0920-1154-18WU

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Focus Group Discussion Guide - OB-GYN/PEDS/MIDWIVES/NPs			Attachment F - Focus Group Discussion Guide.docx	NA	No		Paper Only
Form	0920-1154	ACOG Zika Virus Survey	Attachment A - Survey of Ob-Gyns Mailed.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154	Focus Group Recruitment Screen	Attachment G - Focus Group Recruitment Screener.docx	NA	No		Paper Only
Form and Instruction	0920-1154	ACOG Evaluation of Local Health Department Initiative	Attachment I - LHD Survey.docx	NA	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,422

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,422	4,422
Annual IC Time Burden (Hours)	835	835
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Email Invitation (OB-GYN)	Attachment B - Survey of Ob-Gyns Email Invitation.docx	05/04/2018
Email Reminder (OB-GYN)	Attachment C - Survey of Ob-Gyns Email Reminders.docx	05/04/2018
Cover Letter Invitation	Attachment D - Survey of Ob-Gyns Mailing Cover Letter.docx	05/04/2018
IRB Approval	Attachment E - Survey of Ob-Gyns IRB Approval.pdf	05/04/2018
Email Invitation (Local Health Department)	Attachment J - LHD Survey Email Invitation.docx	05/04/2018
Email Reminder	Attachment K - LHD Survey Email Reminders.DOCX	05/04/2018
IRB Approval (Local Health Department)	Attachment L - LHD Survey IRB Approval.docx	05/04/2018
ACOG Focus Group IRB Approval	Attachment H - Focus Group IRB Approval.docx	05/04/2018
Supporting Statement A	Revised Supporting Statement A 04MAY2018.docx	05/04/2018
Supporting Statement B	Revised Supporting Statement B 04MAY2018.docx	05/04/2018

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