Neonate Assessment at Delivery Form

US Zika Pregnancy Registry

Documents and Forms

Document Name Document Type
Neonate Assessment at Delivery Form Form and Instruction
Neonate Assessment at Delivery Form ATT_C_USZPR_Neonate_Assessment_At_Delivery_Revised 21SEP2016.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Neonate Assessment at Delivery 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	Neonate Assessment at Delivery Form	ATT_C_USZPR_Neonate_Assessment_At_Delivery_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: 600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,000	-5,000	11,000
Annual IC Time Burden (Hours)	3,000	-2,500	5,500
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.