30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey

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

Documents and Forms

Document Name Document Type
30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey Form and Instruction
Att H-3 Patient Survey 30 mo version B (Eng and Span).docx Other-Word version of survey content
Screenshots of the 30-month Follow-up Survey (Version B Att H-6 Patient Survey 30 mo Ver B Screen Shots.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey	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 30-month Follow-up Survey (Version B for Z-CAN patients who did not complete the 18-month Follow-up Survey)	Att H-6 Patient Survey 30 mo Ver B Screen Shots.pdf		Yes	Yes	Fillable Fileable
Other-Word version of survey content for reference/editing (English and Spanish)			Att H-3 Patient Survey 30 mo version B (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: 220	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	220	220
Annual IC Time Burden (Hours)	37	37
Annual IC Cost Burden (Dollars)	266	266

Documents for IC

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.