Information Collection

Survey and Consent - Zika Reproductive Health and Emergency Response Call-Back Survey (ZRHER), 2018

IC 229888 under ICR 201805-0920-011 · OMB 0920-1223.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Survey and Consent - Zika Reproductive Health and Emergency Response Call-Back Survey (ZRHER), 2018	Form and Instruction
Survey and Consent - ZRHER Att 5 ZRHER Survey and Consent_11-3-2017.docx	Form and Instruction
Survey and Consent - ZRHER Spanish Att 5S ZRHER Survey and Consent SPANISH.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Survey and Consent - ZRHER	Att 5 ZRHER Survey and Consent_11-3-2017.docx	NA	No		Paper Only
Form and Instruction	NA	Survey and Consent - ZRHER Spanish	Att 5S ZRHER Survey and Consent SPANISH.docx	NA	No		Paper Only

Line of Business: Disaster Management

Subfunction: Disaster Preparedness and Planning

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,700

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	9,700	9,700
Annual IC Time Burden (Hours)	1,617	1,617
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.