Hospital-based Survey for Mothers

Zika Postpartum Emergency Response Survey (ZPER) - Puerto Rico 2017

Documents and Forms

Document Name Document Type
Hospital-based Survey for Mothers Form and Instruction
ZPER Maternal Hospital-based Questionnaire - English Att 7a Hospital-based Survey for Mothers _English.doc Form and Instruction
ZPER Maternal Hospital-based Questionnaire - Spanish Att 7b Hospital-based Survey for Mothers_Spanish.doc.docx Form and Instruction
Maternal Hospital-based Questionnaire - English Screensh Att 7c Hospital-based Survey for Mothers_English_tablet screenshots.pdf Form and Instruction
ZPER Maternal Hospital-based Questionnaire - Spanish Scr Att 7d Hospital-based Survey for Mothers_Spanish_table screenshots.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Hospital-based Survey for Mothers	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	ZPER Maternal Hospital-based Questionnaire - Spanish	Att 7b Hospital-based Survey for Mothers_Spanish.doc.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Maternal Hospital-based Questionnaire - English Screenshot	Att 7c Hospital-based Survey for Mothers_English_tablet screenshots.pdf	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	ZPER Maternal Hospital-based Questionnaire - English	Att 7a Hospital-based Survey for Mothers _English.doc	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	ZPER Maternal Hospital-based Questionnaire - Spanish Screenshot	Att 7d Hospital-based Survey for Mothers_Spanish_table screenshots.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: 3,120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,120	3,120
Annual IC Time Burden (Hours)	1,300	1,300
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.