Puerto Rico BRFSS Coordinator - Data submission

Zika Reproductive Health Call-Back Survey (ZRHCS), PUERTO RICO 2017

Documents and Forms

Document Name Document Type
Puerto Rico BRFSS Coordinator - Data submission Form and Instruction
Recruitment Script Data Att 2 ZRHCS Recruitment Script.docx Form and Instruction
Call Back Survey Data Att 3 ZRHCS Survey.DOCX Form and Instruction

Information Collection (IC) Details

IC Title:	Puerto Rico BRFSS Coordinator - Data submission	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	Recruitment Script Data	Att 2 ZRHCS Recruitment Script.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Call Back Survey Data	Att 3 ZRHCS Survey.DOCX	NA	Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6	6
Annual IC Time Burden (Hours)	18	18
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.