Pregnant Women - Adult Symptoms Questionnaire

ZEN Colombia Study: Zika in Pregnant Women and Children in Colombia

Documents and Forms

Document Name Document Type
Pregnant Women - Adult Symptoms Questionnaire Form and Instruction
ZEN Columbia - Adult Symptoms Questionnaire - English Att B5 - Adult Symptoms_052517_CLEAN.docx Form and Instruction
ZEN Colombia: Adult Symptoms - Spanish Att C5_Sintomas Adultos_Formatted_071317_CLEAN.DOCX Form

Information Collection (IC) Details

IC Title:	Pregnant Women - Adult Symptoms Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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 - Adult Symptoms Questionnaire - English	Att B5 - Adult Symptoms_052517_CLEAN.docx	NA	No		Paper Only
Form	none	ZEN Colombia: Adult Symptoms - Spanish	Att C5_Sintomas Adultos_Formatted_071317_CLEAN.DOCX		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	Previously Approved
Annual Number of Responses for this IC	7,500	7,500
Annual IC Time Burden (Hours)	1,250	1,250
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.