Pregnant Women - Ages and Stages: 12 and 24 Month 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⚠️ Notice: This information collection may be referencing outdated material.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 - Ages and Stages: 12 and 24 Month Questionnaire Form and Instruction
Ages and Stages Questionnaire - 12 month English Att B11_Ages and Stages_12_Months.pdf Form and Instruction
Ages and Stages Questionnaire - 12 month Spanish Att C11_Ages and Stages_12_Months_spanish.pdf Form and Instruction
Ages and Stages Questionnaire - 24 month English Att B13_Ages and Stages_24_Months.pdf Form and Instruction
Ages and Stages Questionnaire - 24 month Spanish Att C13_Ages and Stages-24_Months_Spanish.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Pregnant Women - Ages and Stages: 12 and 24 Month Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Electronic Capability
Form and Instruction	NA	Ages and Stages Questionnaire - 12 month English	Att B11_Ages and Stages_12_Months.pdf	NA	No	Paper Only
Form and Instruction	NA	Ages and Stages Questionnaire - 12 month Spanish	Att C11_Ages and Stages_12_Months_spanish.pdf	NA	No	Paper Only
Form and Instruction	NA	Ages and Stages Questionnaire - 24 month English	Att B13_Ages and Stages_24_Months.pdf	NA	No	Paper Only
Form and Instruction	NA	Ages and Stages Questionnaire - 24 month Spanish	Att C13_Ages and Stages-24_Months_Spanish.pdf	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: 900	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
Annual Number of Responses for this IC	1,800	1,800
Annual IC Time Burden (Hours)	450	450
Annual IC Cost Burden (Dollars)	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.