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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 232333 under ICR 201902-0920-017 · OMB 0920-1241.

Documents and Forms
Document Name
Document Type
Form and Instruction
Other-Word version of survey content
Form and Instruction
IC Document
Information Collection (IC) Details

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18-month Follow-up Survey for Z-CAN patients
 
No Unchanged
 
Voluntary
 

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

Disaster Management Emergency Response

09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems   57 FR 62812

960 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 960 0 0 0 0 960
Annual IC Time Burden (Hours) 112 0 0 0 0 112
Annual IC Cost Burden (Dollars) 812 0 0 0 0 812

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.