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
Onsline Survey - Patient 18 yr 12-month Follow-Up Spanish/Screenshot Form and Instruction New Available
Onsline Survey - Patient 18 yr 12-month Follow-Up English Form and Instruction New Available
Onsline Survey - Patient 18 yr 6-month Follow-Up Spanish/Screenshot Form and Instruction New Available
Onsline Survey - Patient 18 yr 6-month Follow-Up English Form and Instruction New Available
Online Survey - Staff Spanish/Screenshot Form and Instruction New Available
Online Survey - Staff English Form and Instruction New Available
Online Survey Physician Spanish/Screenshot Form and Instruction New Available
Online Survey - Physician English Form and Instruction New Available
Individual Interview Guide - Staff Spanish Form and Instruction New Available
Individual Interview Guide - Staff English Form and Instruction New Available
Individual Interview Guide - Physicians Spanish Form and Instruction New Available
Individual Interview Guide - Physicians English Form and Instruction New Available
Focus Group Guide Non-Z-CAN Women Spanish Form and Instruction New Available
Focus Group Guide - Non-Z-CAN Women English Form and Instruction New Available
Focus Group Guide Z-CAN Women Spanish Form and Instruction New Available
Focus Group Guide - Z-CAN Women English Form and Instruction New Available
Focus Group Screener - Women Screenshot Form and Instruction New Available
Focus Group Screener - Women Spanish Form and Instruction New Available
Focus Group Screener - Women English 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 NewOnsline Survey - Patient 18 yr 12-month Follow-Up Spanish/Screenshot
225613 Online Survey - 12 month Follow-Up - Patients 18 years or older Form and Instruction NewOnsline Survey - Patient 18 yr 12-month Follow-Up English
225612 Online Survey - 6 month Follow-Up - Patients 18 years or older Form and Instruction NewOnsline Survey - Patient 18 yr 6-month Follow-Up Spanish/Screenshot
225612 Online Survey - 6 month Follow-Up - Patients 18 years or older Form and Instruction NewOnsline Survey - Patient 18 yr 6-month Follow-Up English
225611 Online Survey - Z-CAN Staff Form and Instruction NewOnline Survey - Staff Spanish/Screenshot
225611 Online Survey - Z-CAN Staff Form and Instruction NewOnline Survey - Staff English
225610 Online Survey - Z-CAN Physician Form and Instruction NewOnline Survey Physician Spanish/Screenshot
225610 Online Survey - Z-CAN Physician Form and Instruction NewOnline Survey - Physician English
225609 Semi-structured Individual Interview - Z-CAN Staff Form and Instruction NewIndividual Interview Guide - Staff Spanish
225609 Semi-structured Individual Interview - Z-CAN Staff Form and Instruction NewIndividual Interview Guide - Staff English
225608 Semi-structured Individual Interview - Z-CAN Physicians Form and Instruction NewIndividual Interview Guide - Physicians Spanish
225608 Semi-structured Individual Interview - Z-CAN Physicians Form and Instruction NewIndividual Interview Guide - Physicians English
225607 Focus Group Guide - Women 18 years or older / able to conceive Form and Instruction NewFocus Group Guide Non-Z-CAN Women Spanish
225607 Focus Group Guide - Women 18 years or older / able to conceive Form and Instruction NewFocus Group Guide - Non-Z-CAN Women English
225607 Focus Group Guide - Women 18 years or older / able to conceive Form and Instruction NewFocus Group Guide Z-CAN Women Spanish
225607 Focus Group Guide - Women 18 years or older / able to conceive Form and Instruction NewFocus Group Guide - Z-CAN Women English
225606 Focus Group Screener - Women 18 years or older / able to conceive Form and Instruction NewFocus Group Screener - Women Screenshot
225606 Focus Group Screener - Women 18 years or older / able to conceive Form and Instruction NewFocus Group Screener - Women Spanish
225606 Focus Group Screener - Women 18 years or older / able to conceive Form and Instruction NewFocus Group Screener - Women English

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
Focus Group Guide - Women 18 years or older / able to conceive NA, NA, NA, NA ,   ,   ,  
Focus Group Screener - Women 18 years or older / able to conceive NA, NA, NA ,   ,  
Online Survey - 12 month Follow-Up - Patients 18 years or older NA, NA ,  
Online Survey - 6 month Follow-Up - Patients 18 years or older NA, NA ,  
Online Survey - Z-CAN Physician NA, NA ,  
Online Survey - Z-CAN Staff NA, NA ,  
Semi-structured Individual Interview - Z-CAN Physicians NA, NA ,  
Semi-structured Individual Interview - Z-CAN Staff NA, NA ,  

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