Eligibility Form

Form Approved

OMB Control No.: 0920-1140

Expiration date: 10/31/2017

Attachment D. Eligibility Form

#	Pregunta	Opciones	Skip
E1	Are you a resident of Puerto Rico?	0, No 1, Si	If no (0), participant is not eligible; end visit. Else, continue to E2.
E2	Have you participated in the Ziper study before as a participant with Zika?	0, No 1, Si	If yes (1), participant is not eligible, end visit. Else, continue to E3.
E3	For Interviewer: Is this a ZKV+ participant or household contact?	1, ZKV+ 2, Household contact	If ZKV+ (1), the participant is eligible. End of eligibility screener. If contacto, continue to E4.
E4	Do you have a coupon?	0, No 1, Si	If no, ineligible; end interview. Else, continue to E5.
E5	Do you live with the person who referred you?	0, No 1, Si	If no (0), ineligible, end survey. Else, eligible; continue to survey tool (A1).

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1140