Information Collection

Pregnant Women - Adult Symptoms Questionnaire

IC 226473 under ICR 201709-0920-001 · OMB 0920-1190.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1190 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Pregnant Women - Adult Symptoms Questionnaire	Form and Instruction
ZEN Columbia - Adult Symptoms Questionnaire - English Att B5 - Adult Symptoms_052517_CLEAN.docx	Form and Instruction
ZEN Colombia: Adult Symptoms - Spanish Att C5_Sintomas Adultos_Formatted_071317_CLEAN.DOCX	Form

IC Title:

Pregnant Women - Adult Symptoms Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	ZEN Columbia - Adult Symptoms Questionnaire - English	Att B5 - Adult Symptoms_052517_CLEAN.docx	NA	No		Paper Only
Form	none	ZEN Colombia: Adult Symptoms - Spanish	Att C5_Sintomas Adultos_Formatted_071317_CLEAN.DOCX		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0113 - Epidemic Investigation Case Records System

FR Citation: 51 FR 42466

Number of Respondents: 2,500

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	Previously Approved
Annual Number of Responses for this IC	37,500	37,500
Annual IC Time Burden (Hours)	6,250	6,250
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.