18-month Follow-up Survey for Z-CAN patients

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

Documents and Forms

Document Name Document Type
18-month Follow-up Survey for Z-CAN patients Form and Instruction
Att H-1 Patient Survey 18 mo (Eng and Span)_07022018.docx Other-Word version of survey content
Screenshots of the 18-month Follow-up Survery for Z-CAN Att H-4 Patient Survey 18 mo Screen Shots_07022018.pdf Form and Instruction
Att H-1 Patient Survey 18 mo (Eng and Span)_07022018.docx Word version of 18-month survey content for reference/editing IC Document

Information Collection (IC) Details

IC Title:	18-month Follow-up Survey for Z-CAN patients	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	n/a	Screenshots of the 18-month Follow-up Survery for Z-CAN patients ages 18+	Att H-4 Patient Survey 18 mo Screen Shots_07022018.pdf		Yes	Yes	Fillable Fileable
Other-Word version of survey content for reference/editing (English and Spanish)			Att H-1 Patient Survey 18 mo (Eng and Span)_07022018.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: 960	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	960	960
Annual IC Time Burden (Hours)	112	112
Annual IC Cost Burden (Dollars)	812	812

Documents for IC

Title	Document	Date Uploaded
Word version of 18-month survey content for reference/editing	Att H-1 Patient Survey 18 mo (Eng and Span)_07022018.docx	07/20/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.