Online Survey - Z-CAN Staff

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

Documents and Forms

Document Name Document Type
Online Survey - Z-CAN Staff Form and Instruction
Online Survey - Staff English Att N-3 Online Survey_Staff (Eng).docx Form and Instruction
Online Survey - Staff Spanish/Screenshot Att N-4 Screen shots_Online survey_Staff (Span).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Online Survey - Z-CAN Staff	Agency IC Tracking Number:

Is this a Common Form? No		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	NA	Online Survey - Staff English	Att N-3 Online Survey_Staff (Eng).docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Online Survey - Staff Spanish/Screenshot	Att N-4 Screen shots_Online survey_Staff (Span).pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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