Pregnant Women - Pregnant Women Eligibility Questionnaire

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Pregnant Women - Pregnant Women Eligibility Questionnaire Form and Instruction
ZEN Columbia: Pregnant Women Eligibility - English 08SEP Att B1 - Woman Eligibility Screening Form_090617_clean.docx Form and Instruction
ZEN Columbia: Pregnant Women Eligibility - Spanish 08SEP Att C1_Form de Eleg_Mujeres_090617_CLEAN.DOCX Form and Instruction

Information Collection (IC) Details

IC Title:	Pregnant Women - Pregnant Women Eligibility Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	ZEN Columbia: Pregnant Women Eligibility - English 08SEP2017	Att B1 - Woman Eligibility Screening Form_090617_clean.docx	NA	No		Paper Only
Form and Instruction	NA	ZEN Columbia: Pregnant Women Eligibility - Spanish 08SEP2017	Att C1_Form de Eleg_Mujeres_090617_CLEAN.DOCX	NA	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: 600	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	Previously Approved
Annual Number of Responses for this IC	600	-2,525	3,125
Annual IC Time Burden (Hours)	50	-210	260
Annual IC Cost Burden (Dollars)	0	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.