Pregnant Women Follow-Up Questionnaire

Zika Virus RNA Persistence in Pregnant Women and Congenitally Exposed Infants in Puerto Rico (ZIRP)

Documents and Forms

Document Name Document Type
Pregnant Women Follow-Up Questionnaire Form and Instruction
Pregnant Women Follow-Up Questionnaire - English Att C4 - Pregnant Woman Follow-up_final Spanish.docx Form and Instruction
Pregnant Women Follow-Up Questionnaire - Spanish Att C4 - Pregnant Woman Follow-up_final Spanish.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Pregnant Women Follow-Up Questionnaire	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	Pregnant Women Follow-Up Questionnaire - English	Att C4 - Pregnant Woman Follow-up_final Spanish.docx	NA	No		Paper Only
Form and Instruction	NA	Pregnant Women Follow-Up Questionnaire - Spanish	Att C4 - Pregnant Woman Follow-up_final Spanish.docx	NA	No		Paper Only

Line of Business: Disaster Management

Subfunction: Emergency Response

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: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,500	4,500
Annual IC Time Burden (Hours)	600	600
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.