ZEN Colombia Study: Zika in Pregnant Women and Children in Colombia

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Ages and Stages Questionnaire - 4 month Spanish	Form and Instruction	Modified	Available
Ages and Stages Questionnaire - 4 month English	Form and Instruction	Modified	Available
Ages and Stages Questionnaire - 6 month Spanish	Form and Instruction	Modified	Available
Ages and Stages Questionnaire - 6 month English	Form and Instruction	Modified	Available
Ages and Stages Questionnaire - 2 month Spanish	Form and Instruction	Unchanged	Available
Ages and Stages Questionnaire - 2 month English	Form and Instruction	Unchanged	Available
ZEN Colombia: Adult Symptoms - Spanish	Form	Unchanged	Available
ZEN Columbia - Adult Symptoms Questionnaire - English	Form and Instruction	Unchanged	Repair queued
ZEN Columbia: Male Partner Enrollment Questionnaire - Spanish 08SEP2017	Form and Instruction	Unchanged	Available
ZEN Columbia - Male Partner Enrollment Questionnaire - English 26MAY2017	Form and Instruction	Unchanged	Available
ZEN Colombia : Male Partner Eligibility - Spanish	Form	Unchanged	Available
ZEN Columbia - Male Partner Eligibility - English 26MAY2017	Form and Instruction	Unchanged	Available
ZEN Columbia: Infant Symptoms - Spanish 08SEP2017	Form	Unchanged	Available
ZEN Colombia: Infant Symptoms - English	Form	Unchanged	Available
ZEN Columbia: Pregnant Women Follow-Up Questionnaire - Spanish 08SEP2017	Form and Instruction	Unchanged	Available
ZEN Columbia: Pregnant Women Follow-Up Questionnaire - English 08SEP2017	Form and Instruction	Unchanged	Available
ZEN Colombia: Adult Symptoms - Spanish	Form	Unchanged	Available
ZEN Columbia - Adult Symptoms Questionnaire - English	Form and Instruction	Unchanged	Available
ZEN Columbia: Pregnant Women Enrollment Questionnaire - Spanish 08SEP2017	Form and Instruction	Unchanged	Available
ZEN Columbia - Pregnant Woman Enrollment Questionnaire - English 26MAY2017	Form and Instruction	Unchanged	Available
ZEN Columbia: Pregnant Women Eligibility - Spanish 08SEP2017	Form and Instruction	Unchanged	Available
ZEN Columbia: Pregnant Women Eligibility - English 08SEP2017	Form and Instruction	Unchanged	Available
0920-1190_Change_Request_Justification_092717 JZ.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-10-04	Available
0920-1190_Change_Request_Justification_090617_submit.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-09-08	Available
0920-17ABB_Change_Request_Justification_06JUL17.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-07-18	Available
ZEN Colombia_SSA Part A 092817.docx	Supporting Statement A	Uploaded 2017-10-04	Available
SSB Part B 09JUN2017.docx	Supporting Statement B	Uploaded 2017-06-12	Available
ATT_E3_6921 Vysnova relying on CDC.PDF	Supplementary Document	Uploaded 2017-03-29	Available
ATT_E2_INS_ethics_approval_ZEN_English_12122016.docx	Supplementary Document	Uploaded 2017-03-29	Available
Att_E1_6921_IRB_Amendment #3 approval.docx	Supplementary Document	Uploaded 2017-03-29	Available
ATT_D3_Infant Permission Form 030117_CLEAN.docx	Supplementary Document	Uploaded 2017-03-29	Available
ATT_D2_Male Participant Informed Consent 022217_CLEAN.docx	Supplementary Document	Uploaded 2017-03-29	Available
ATT_D1_Pregnant Woman Informed Consent 03012017_CLEAN.docx	Supplementary Document	Uploaded 2017-03-29	Available
Att_F2_FTE Nondisclosure.DOCX	Supplementary Document	Uploaded 2017-03-29	Available
Att_F3_Agreement to abide by restrictions.docx	Supplementary Document	Uploaded 2017-03-29	Available
Att_F1_Assurance of Confidentiality Zika Surveillance Final.doc	Supplementary Document	Uploaded 2017-03-29	Available
2016-27691 (002)_60Day FRN.pdf	Supplementary Document	Uploaded 2017-03-28	Available
Att_A_Section 301 of Public Health Service Act (42 U.S.C. 241).docx	Supplementary Document	Uploaded 2017-03-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
226998	Pregnant Women - Ages and Stages 6 Month Questionnaire	Form and Instruction	Modified	Ages and Stages Questionnaire - 4 month Spanish
226998	Pregnant Women - Ages and Stages 6 Month Questionnaire	Form and Instruction	Modified	Ages and Stages Questionnaire - 4 month English
226998	Pregnant Women - Ages and Stages 6 Month Questionnaire	Form and Instruction	Modified	Ages and Stages Questionnaire - 6 month Spanish
226998	Pregnant Women - Ages and Stages 6 Month Questionnaire	Form and Instruction	Modified	Ages and Stages Questionnaire - 6 month English
226997	Pregnant Women - Ages and Stages 2 Month Questionnaire	Form and Instruction	Unchanged	Ages and Stages Questionnaire - 2 month Spanish
226997	Pregnant Women - Ages and Stages 2 Month Questionnaire	Form and Instruction	Unchanged	Ages and Stages Questionnaire - 2 month English
226478	Male Partners - Adult Symptoms Questionnaire	Form	Unchanged	ZEN Colombia: Adult Symptoms - Spanish
226478	Male Partners - Adult Symptoms Questionnaire	Form and Instruction	Unchanged	ZEN Columbia - Adult Symptoms Questionnaire - English
226477	Male Partners - Male Enrollment Questionnaire	Form and Instruction	Unchanged	ZEN Columbia: Male Partner Enrollment Questionnaire - Spanish 08SEP2017
226477	Male Partners - Male Enrollment Questionnaire	Form and Instruction	Unchanged	ZEN Columbia - Male Partner Enrollment Questionnaire - English 26MAY2017
226476	Male Partners - Male Partner Eligibility Questionnaire	Form	Unchanged	ZEN Colombia : Male Partner Eligibility - Spanish
226476	Male Partners - Male Partner Eligibility Questionnaire	Form and Instruction	Unchanged	ZEN Columbia - Male Partner Eligibility - English 26MAY2017
226475	Pregnant Women - Infant Symptoms Questionnaire	Form	Unchanged	ZEN Columbia: Infant Symptoms - Spanish 08SEP2017
226475	Pregnant Women - Infant Symptoms Questionnaire	Form	Unchanged	ZEN Colombia: Infant Symptoms - English
226474	Pregnant Women - Pregnant Women Follow-Up Questionnaire	Form and Instruction	Unchanged	ZEN Columbia: Pregnant Women Follow-Up Questionnaire - Spanish 08SEP2017
226474	Pregnant Women - Pregnant Women Follow-Up Questionnaire	Form and Instruction	Unchanged	ZEN Columbia: Pregnant Women Follow-Up Questionnaire - English 08SEP2017
226473	Pregnant Women - Adult Symptoms Questionnaire	Form	Unchanged	ZEN Colombia: Adult Symptoms - Spanish
226473	Pregnant Women - Adult Symptoms Questionnaire	Form and Instruction	Unchanged	ZEN Columbia - Adult Symptoms Questionnaire - English
226472	Pregnant Women - Pregnant Women Enrollment Questionnaire	Form and Instruction	Unchanged	ZEN Columbia: Pregnant Women Enrollment Questionnaire - Spanish 08SEP2017
226472	Pregnant Women - Pregnant Women Enrollment Questionnaire	Form and Instruction	Unchanged	ZEN Columbia - Pregnant Woman Enrollment Questionnaire - English 26MAY2017
226464	Pregnant Women - Pregnant Women Eligibility Questionnaire	Form and Instruction	Unchanged	ZEN Columbia: Pregnant Women Eligibility - Spanish 08SEP2017
226464	Pregnant Women - Pregnant Women Eligibility Questionnaire	Form and Instruction	Unchanged	ZEN Columbia: Pregnant Women Eligibility - English 08SEP2017

ICR Details

OMB Control No: 0920-1190	ICR Reference No: 201710-0920-001
Status: Historical Active	Previous ICR Reference No: 201709-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1190-18AB
Title: ZEN Colombia Study: Zika in Pregnant Women and Children in Colombia
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/05/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/05/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2019	07/31/2019	07/31/2019
Responses	106,625	0	106,625
Time Burden (Hours)	20,541	0	20,541
Cost Burden (Dollars)	0	0	0

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Abstract: CDC is requesting a Non-Substantive Change to the OMB approved collection 0920-1190 ZEN Colombia Study: Zika in Pregnant Women and Children in Colombia to add a 4 month Ages and Stages Questionnaire. This questionnaire would be in lieu of the 6 month Ages and Stages Questionnaire for infants born premature as they would not be able to meet the milestones indicated in the 6 month questionnaire. Therefore, there is no change to the estimated burden per response.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: U.S. PHSA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 81144	11/17/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 26930	06/12/2017
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Male Partners - Adult Symptoms Questionnaire	NA, none	ZEN Columbia - Adult Symptoms Questionnaire - English ,   ZEN Colombia: Adult Symptoms - Spanish
Male Partners - Male Enrollment Questionnaire	NA, NA	ZEN Columbia - Male Partner Enrollment Questionnaire - English 26MAY2017 ,   ZEN Columbia: Male Partner Enrollment Questionnaire - Spanish 08SEP2017
Male Partners - Male Partner Eligibility Questionnaire	none, NA	ZEN Columbia - Male Partner Eligibility - English 26MAY2017 ,   ZEN Colombia : Male Partner Eligibility - Spanish
Pregnant Women - Adult Symptoms Questionnaire	none, NA	ZEN Columbia - Adult Symptoms Questionnaire - English ,   ZEN Colombia: Adult Symptoms - Spanish
Pregnant Women - Ages and Stages 2 Month Questionnaire	NA, NA	Ages and Stages Questionnaire - 2 month English ,   Ages and Stages Questionnaire - 2 month Spanish
Pregnant Women - Ages and Stages 6 Month Questionnaire	NA, NA, NA, NA	Ages and Stages Questionnaire - 6 month English ,   Ages and Stages Questionnaire - 6 month Spanish ,   Ages and Stages Questionnaire - 4 month English ,   Ages and Stages Questionnaire - 4 month Spanish
Pregnant Women - Infant Symptoms Questionnaire	NA, none	ZEN Colombia: Infant Symptoms - English ,   ZEN Columbia: Infant Symptoms - Spanish 08SEP2017
Pregnant Women - Pregnant Women Eligibility Questionnaire	NA, NA	ZEN Columbia: Pregnant Women Eligibility - English 08SEP2017 ,   ZEN Columbia: Pregnant Women Eligibility - Spanish 08SEP2017
Pregnant Women - Pregnant Women Enrollment Questionnaire	NA, NA	ZEN Columbia - Pregnant Woman Enrollment Questionnaire - English 26MAY2017 ,   ZEN Columbia: Pregnant Women Enrollment Questionnaire - Spanish 08SEP2017
Pregnant Women - Pregnant Women Follow-Up Questionnaire	NA, NA	ZEN Columbia: Pregnant Women Follow-Up Questionnaire - English 08SEP2017 ,   ZEN Columbia: Pregnant Women Follow-Up Questionnaire - Spanish 08SEP2017

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	106,625	106,625	0	0	0	0
Annual Time Burden (Hours)	20,541	20,541	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $4,105,479

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/05/2017

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