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Information Collection

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

IC 232334 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
Information Collection (IC) Details

View Information Collection (IC)

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

Disaster Management Emergency Response

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

660 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 660 0 0 0 0 660
Annual IC Time Burden (Hours) 110 0 0 0 0 110
Annual IC Cost Burden (Dollars) 797 0 0 0 0 797

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