Online Survey - 6 month Follow-Up - Patients 18 years or older

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

Documents and Forms

Document Name Document Type
Online Survey - 6 month Follow-Up - Patients 18 years or older Form and Instruction
Onsline Survey - Patient 18 yr 6-month Follow-Up English Att R-1 Patient Survey_6 mo_12 mo vA (Eng).docx Form and Instruction
Onsline Survey - Patient 18 yr 6-month Follow-Up Spanish Att R-2 Screen shots_Patient Survey_6 mo_12 mo vA (Span).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Online Survey - 6 month Follow-Up - Patients 18 years or older	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	Onsline Survey - Patient 18 yr 6-month Follow-Up English	Att R-1 Patient Survey_6 mo_12 mo vA (Eng).docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Onsline Survey - Patient 18 yr 6-month Follow-Up Spanish/Screenshot	Att R-2 Screen shots_Patient Survey_6 mo_12 mo vA (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: 800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	133	133
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.