Information Collection

30-month Follow-up Survey for Z-CAN patients who completed the 18-month Follow-up Survey

IC 232334 under ICR 201806-0920-010 · OMB 0920-1241.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1241 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
30-month Follow-up Survey for Z-CAN patients who completed the 18-month Follow-up Survey	Form and Instruction
Att H-2 Patient Survey 30 mo version A (Eng and Span).docx	Other-Word version of survey content
Screenshots of the 30-month Follow-up Survey (Version A Att H-5 Patient Survey 30 mo Ver A Screen Shots.pdf	Form and Instruction

IC Title:

30-month Follow-up Survey for Z-CAN patients who completed the 18-month Follow-up Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	n/a	Screenshots of the 30-month Follow-up Survey (Version A for Z-CAN patients who completed the 18-month Follow-up Survey)	Att H-5 Patient Survey 30 mo Ver A Screen Shots.pdf		Yes	Yes	Fillable Fileable
Other-Word version of survey content for reference/editing (English and Spanish)			Att H-2 Patient Survey 30 mo version A (Eng and Span).docx		No		Paper Only

Line of Business: Disaster Management

Subfunction: Emergency Response

Privacy Act System of Records

Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 660

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	660	660
Annual IC Time Burden (Hours)	110	110
Annual IC Cost Burden (Dollars)	797	797

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.