Information Collection

Pregnant Women Symptom Questionnaire

IC 227419 under ICR 201706-0920-003 · OMB 0920-1189.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Pregnant Women Symptom Questionnaire	Form and Instruction
Pregnant Women Symptom Questionnaire - English Att C3 - Pregnant Woman Symptom Questionnaire.docx	Form and Instruction
Pregnant Women Symptom Questionnaire - Spanish Att C3 - Pregnant Woman Symptom_final Spanish.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Pregnant Women Symptom Questionnaire - English	Att C3 - Pregnant Woman Symptom Questionnaire.docx	NA	No		Paper Only
Form and Instruction	NA	Pregnant Women Symptom Questionnaire - Spanish	Att C3 - Pregnant Woman Symptom_final Spanish.docx	NA	No		Paper Only

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records

Title: 09-20-0136, âEpidemiologic Studies and Surveillance of Disease Problems.â

FR Citation: 57 FR 62812

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.