Assessment of a Preventive Service Program in the Context of a Zika Virus Outbreak in Puerto Rico

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Screenshots of the 30-month Follow-up Survey (Version B for Z-CAN patients who did not complete the 18-month Follow-up Survey)	Form and Instruction	Unchanged	Available
Screenshots of the 30-month Follow-up Survey (Version A for Z-CAN patients who completed the 18-month Follow-up Survey)	Form and Instruction	Unchanged	Available
Screenshots of the 18-month Follow-up Survery for Z-CAN patients ages 18+	Form and Instruction	Unchanged	Available
0920-1241 Change Request Justification 2-15-2019.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2019-02-22	Available
Att I Referenced articles.pdf	Supplementary Document	Uploaded 2018-07-20	Available
Att G Consent_Online Survey_18_30_ZCAN women (Eng and Span).docx	Supplementary Document	Uploaded 2018-07-20	Available
Att F Invitation_Online Survey_18_30_ZCAN women (Eng and Span).docx	Supplementary Document	Uploaded 2018-07-20	Available
Att E Interim contacts with ZCAN women (Eng and Span).docx	Supplementary Document	Uploaded 2018-07-20	Available
Att D-2 UPR IRB approval letter.pdf	Supplementary Document	Uploaded 2018-07-20	Available
Att D-1 CDC IRB approval letter.pdf	Supplementary Document	Uploaded 2018-07-20	Available
Att C Privacy Act Determination.pdf	Supplementary Document	Uploaded 2018-07-20	Available
Att B-1 60-day FRN March 30 2018.pdf	Supplementary Document	Uploaded 2018-07-20	Available
Att A-Section 301 of the PHS Act.pdf	Supplementary Document	Uploaded 2018-07-20	Available
SSB_Z-CAN_07022018.docx	Supporting Statement B	Uploaded 2018-07-20	Available
SSA_Z-CAN_07022018.docx	Supporting Statement A	Uploaded 2018-07-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
232335	30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey	Other-Word version of survey content for reference/editing (Engl	Unchanged
232335	30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey	Form and Instruction	Unchanged	Screenshots of the 30-month Follow-up Survey (Version B for Z-CAN patients who did not complete the 18-month Follow-up Survey)
232334	30-month Follow-up Survey for Z-CAN patients who completed the 18-month Follow-up Survey	Other-Word version of survey content for reference/editing (Engl	Unchanged
232334	30-month Follow-up Survey for Z-CAN patients who completed the 18-month Follow-up Survey	Form and Instruction	Unchanged	Screenshots of the 30-month Follow-up Survey (Version A for Z-CAN patients who completed the 18-month Follow-up Survey)
232333	18-month Follow-up Survey for Z-CAN patients	Other-Word version of survey content for reference/editing (Engl	Unchanged
232333	18-month Follow-up Survey for Z-CAN patients	Form and Instruction	Unchanged	Screenshots of the 18-month Follow-up Survery for Z-CAN patients ages 18+

ICR Details

OMB Control No: 0920-1241	ICR Reference No: 201902-0920-017
Status: Historical Active	Previous ICR Reference No: 201806-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-1241-19YM
Title: Assessment of a Preventive Service Program in the Context of a Zika Virus Outbreak in Puerto Rico
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/12/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/26/2019
Terms of Clearance: Previous terms continue: Approved consistent with the understanding that CDC - in collaboration with the University of Puerto Rico - is confident that the internet access in Puerto Rico necessary to conduct this information collection is now stable and sufficient.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	08/31/2020	08/31/2020
Responses	1,840	0	1,840
Time Burden (Hours)	259	0	259
Cost Burden (Dollars)	1,875	0	1,875

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Abstract: The purpose of this project is to assess the implementation and associated outcomes of the Zika Contraception Access Network (Z-CAN), an initiative that provided patient-centered services to reproductive-aged women in Puerto Rico who chose to delay or avoid pregnancy while local Zika virus transmission was ongoing. This Non-Substantive Change is being requested to increase the value of the gift card given to women who participate in the 18- and 30-month follow-up surveys as a token of appreciation from $5 to $10 as means to improve participation. The requested change does not affect any other component of the information collection.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 13752	03/30/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 34588	07/20/2018
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
18-month Follow-up Survey for Z-CAN patients	n/a	Screenshots of the 18-month Follow-up Survery for Z-CAN patients ages 18+
30-month Follow-up Survey for Z-CAN patients who completed the 18-month Follow-up Survey	n/a	Screenshots of the 30-month Follow-up Survey (Version A for Z-CAN patients who completed the 18-month Follow-up Survey)
30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey	n/a	Screenshots of the 30-month Follow-up Survey (Version B for Z-CAN patients who did not complete the 18-month Follow-up Survey)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,840	1,840	0	0	0	0
Annual Time Burden (Hours)	259	259	0	0	0	0
Annual Cost Burden (Dollars)	1,875	1,875	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Z-CAN patients will be asked to respond to online surveys at approximately 18 and 30 months after their initial Z-CAN visit. Since women’s satisfaction with their contraceptive method and continued use of that method may vary over time, it is important to assess these outcomes, as well as unmet need for services and reproductive health outcomes over a longer period including after the end of Z-CAN. Some concerns may only become apparent with longer-term assessment, such as changes in utilization or satisfaction with chosen contraceptive methods, whether women are readily able to access services they are eligible for from a Z-CAN provider during or after the program (i.e., no-cost removal of intrauterine devices and implants), and ongoing unmet needs for services after the program. Collecting this information from Z-CAN patients less frequently will preclude this assessment.

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Annual Cost to Federal Government: $706,784

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/26/2019

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