Information Collection Request

Monitoring & Evaluation for the Zika Contraception Access Network (Z-CAN)

ICR 201702-0920-003 · OMB 0920-1164 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Online Survey - 12 month Follow-Up - Patients 18 years or older Form and Instruction New Available
Online Survey - 6 month Follow-Up - Patients 18 years or older Form and Instruction New Available
Online Survey - Z-CAN Staff Form and Instruction New Available
Online Survey - Z-CAN Physician Form and Instruction New Available
Semi-structured Individual Interview - Z-CAN Staff Form and Instruction New Available
Semi-structured Individual Interview - Z-CAN Physicians Form and Instruction New Available
Focus Group Guide - Women 18 years or older / able to conceive Form and Instruction New Available
Focus Group Screener - Women 18 years or older / able to conceive Form and Instruction New Available
Emergency Review Request Memo - Final.pdf Supplementary Document Uploaded 2017-02-08 Available
09-20-0136 57FR62812 SORN.txt Supplementary Document Uploaded 2017-02-08 Available
Att Q Consent_Online Survey_ZCAN women.docx Supplementary Document Uploaded 2017-02-08 Available
Att P-4 Invitation_Online Survey_ZCAN women (Span).docx Supplementary Document Uploaded 2017-02-08 Available
Att P-3 Invitation_Online Survey_ZCAN women (Eng).docx Supplementary Document Uploaded 2017-02-08 Available
Att P-2 Interim contact_Online Survey_ZCAN women (Span).docx Supplementary Document Uploaded 2017-02-08 Available
Att P-1 Interim contact_Online Survey_ZCAN women (Eng).docx Supplementary Document Uploaded 2017-02-08 Available
Att O-2 2 week survey NRD_amended.pdf Supplementary Document Uploaded 2017-02-08 Available
Att O-1 2 week survey NRD.pdf Supplementary Document Uploaded 2017-02-08 Available
Att M-2 Consent_Online Survey_Staff.docx Supplementary Document Uploaded 2017-02-08 Available
Att M-1 Consent_Online Survey_Physicians.docx Supplementary Document Uploaded 2017-02-08 Available
Att L-4 Invitation_Survey_Staff (Span).docx Supplementary Document Uploaded 2017-02-08 Available
Att L-3 Invitation_Survey_Staff (Eng).docx Supplementary Document Uploaded 2017-02-08 Available
Att L-2 Invitation_Survey_Physicians (Span).docx Supplementary Document Uploaded 2017-02-08 Available
Att L-1 Invitation_Survey_Physicians (Eng).docx Supplementary Document Uploaded 2017-02-08 Available
Att J-2 Consent_Interview_Staff.docx Supplementary Document Uploaded 2017-02-08 Available
Att J-1 Consent_Interview_Physicians.docx Supplementary Document Uploaded 2017-02-08 Available
Att I-4 Invitation_Interview_Staff (Span).docx Supplementary Document Uploaded 2017-02-08 Available
Att I-3 Invitation_Interview_Staff (Eng).docx Supplementary Document Uploaded 2017-02-08 Available
Att I-2 Invitation_Interview_Physicians (Span).docx Supplementary Document Uploaded 2017-02-08 Available
Att I-1 Invitation_Interview_Physicians (Eng).docx Supplementary Document Uploaded 2017-02-08 Available
Att G Consent_FGD ZCAN women.docx Supplementary Document Uploaded 2017-02-08 Available
Att E-2 Recruitment flyer (Span).pdf Supplementary Document Uploaded 2017-02-08 Available
Att E-1 Recruitment flyer (Eng).docx Supplementary Document Uploaded 2017-02-08 Available
Att D-2 UPR IRB approval_qual.pdf Supplementary Document Uploaded 2017-02-08 Available
Att D-1 CDC IRB approval letter.pdf Supplementary Document Uploaded 2017-02-08 Available
Att C Privacy Act Determination.pdf Supplementary Document Uploaded 2017-02-08 Available
Att B 60-day FRN 1 25 2017.docx Supplementary Document Uploaded 2017-02-08 Available
SSB_Emergency Zika_Z-CAN 07FEB2017.docx Supporting Statement B Uploaded 2017-02-08 Available
SSA_Emergency Zika_Z-CAN 07FEB2017.docx Supporting Statement A Uploaded 2017-02-08 Available
Att A-Section 301 of the Public Health Service Act (42 USC 241).pdf Supplementary Document Uploaded 2017-02-07 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
225613 Online Survey - 12 month Follow-Up - Patients 18 years or older Form and Instruction New
225612 Online Survey - 6 month Follow-Up - Patients 18 years or older Form and Instruction New
225611 Online Survey - Z-CAN Staff Form and Instruction New
225610 Online Survey - Z-CAN Physician Form and Instruction New
225609 Semi-structured Individual Interview - Z-CAN Staff Form and Instruction New
225608 Semi-structured Individual Interview - Z-CAN Physicians Form and Instruction New
225607 Focus Group Guide - Women 18 years or older / able to conceive Form and Instruction New
225606 Focus Group Screener - Women 18 years or older / able to conceive Form and Instruction New

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
05/31/2017 6 Months From Approved
2,237 0 0
736 0 0
0 0 0





Reginfo record details
8
table that charts list of burden
IC Title Form No. Form Name
Semi-structured Individual Interview - Z-CAN Staff NA, NA Individual Interview Guide - Staff English ,   Individual Interview Guide - Staff Spanish
Online Survey - Z-CAN Physician NA, NA Online Survey - Physician English ,   Online Survey Physician Spanish/Screenshot
Online Survey - Z-CAN Staff NA, NA Online Survey - Staff English ,   Online Survey - Staff Spanish/Screenshot
Focus Group Screener - Women 18 years or older / able to conceive NA, NA, NA Focus Group Screener - Women English ,   Focus Group Screener - Women Spanish ,   Focus Group Screener - Women Screenshot
Semi-structured Individual Interview - Z-CAN Physicians NA, NA Individual Interview Guide - Physicians English ,   Individual Interview Guide - Physicians Spanish
Focus Group Guide - Women 18 years or older / able to conceive NA, NA, NA, NA Focus Group Guide - Z-CAN Women English ,   Focus Group Guide Z-CAN Women Spanish ,   Focus Group Guide - Non-Z-CAN Women English ,   Focus Group Guide Non-Z-CAN Women Spanish
Online Survey - 6 month Follow-Up - Patients 18 years or older NA, NA Onsline Survey - Patient 18 yr 6-month Follow-Up English ,   Onsline Survey - Patient 18 yr 6-month Follow-Up Spanish/Screenshot
Online Survey - 12 month Follow-Up - Patients 18 years or older NA, NA Onsline Survey - Patient 18 yr 12-month Follow-Up English ,   Onsline Survey - Patient 18 yr 12-month Follow-Up Spanish/Screenshot

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 2,237 0 0 2,237 0 0
Annual Time Burden (Hours) 736 0 0 736 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No