Pregnant Women - Pregnant Women Enrollment 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⚠️ Notice: This information collection may be referencing outdated material.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 Enrollment Questionnaire Form and Instruction
ZEN Columbia - Pregnant Woman Enrollment Questionnaire - Att B2 - Maternal Enrollment_052517_CLEAN.docx Form and Instruction
ZEN Columbia: Pregnant Women Enrollment Questionnaire - Att C2_Inscripcion Gestantes_Formatted_090517_clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Pregnant Women - Pregnant Women Enrollment 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 Woman Enrollment Questionnaire - English 26MAY2017	Att B2 - Maternal Enrollment_052517_CLEAN.docx	NA	No		Paper Only
Form and Instruction	NA	ZEN Columbia: Pregnant Women Enrollment Questionnaire - Spanish 08SEP2017	Att C2_Inscripcion Gestantes_Formatted_090517_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: 500	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	500	-2,000	2,500
Annual IC Time Burden (Hours)	292	-1,166	1,458
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.