Supplemental Maternal Prenatal Imaging and Diagnostics Form

US Zika Pregnancy Registry

Documents and Forms

Document Name Document Type
Supplemental Maternal Prenatal Imaging and Diagnostics Form Form and Instruction
Supplemental Maternal Prenatal Imaging and Diagnostics F ATT_B_USZPR_Supplemental_Imaging_Form_Revised 21SEP2016.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Supplemental Maternal Prenatal Imaging and Diagnostics Form	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	Supplemental Maternal Prenatal Imaging and Diagnostics Form	ATT_B_USZPR_Supplemental_Imaging_Form_Revised 21SEP2016.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems; 09-20-0136	FR Citation: 57 FR 62812

Number of Respondents: 665	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,650	-4,350	11,000
Annual IC Time Burden (Hours)	1,108	-725	1,833
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.