Hospital-based Survey for Mothers

Zika Postpartum Emergency Response Survey (ZPER), Puerto Rico, 2017

Documents and Forms

Document Name Document Type
Hospital-based Survey for Mothers Form and Instruction
IN-HOSPITAL MATERNAL SURVEY: English version Att 7a Maternal Hospital Survey_English.docx Form and Instruction
IN-HOSPITAL MATERNAL SURVEY: Spanish version Att 7b Maternal Hospital Survey_Spanish.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Hospital-based Survey for Mothers	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	IN-HOSPITAL MATERNAL SURVEY: English version	Att 7a Maternal Hospital Survey_English.docx	NA	No		Paper Only
Form and Instruction	NA	IN-HOSPITAL MATERNAL SURVEY: Spanish version	Att 7b Maternal Hospital Survey_Spanish.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

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

Number of Respondents: 1,600	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	1,600	-1,390	2,990
Annual IC Time Burden (Hours)	667	-579	1,246
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.