Household Representative Questionnaire

Communities Organized to Prevent Arboviruses: Assessment of Knowledge, Attitudes, and Vector Control Practices and Sero-Prevalence and Incidence of Arborviral Infection in Ponce, Puerto Rico (COPA)

Documents and Forms

Document Name Document Type
Form 0920-18ANU Household Representative Questionnaire Form and Instruction
0920-18ANU Household Representative Questionnaire 4. Attachment 4_EN ES Paper Questionnaire - COPA Y1 COMBINED.pdf Form and Instruction
0920-18ANU Household Representative Questionnaire 4. Attachment 4_EN ES Paper Questionnaire - COPA Y1 COMBINED.pdf Form and Instruction
0920-1254 Household Representative Questionnaire - Data Collection Attachment 3_COPA Data Collection Instruments_combined 07APR2022.pdf Form and Instruction
0920-1254 Household Representative Questionnaire - Data Collection Attachment 3_COPA Data Collection Instruments_combined 07APR2022.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Household Representative Questionnaire	Agency IC Tracking Number:	0920-1254

Is this a Common Form? No		IC Status: Modified

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	0920-18ANU	Household Representative Questionnaire	4. Attachment 4_EN ES Paper Questionnaire - COPA Y1 COMBINED.pdf	NA	No		Fillable Fileable
Form and Instruction	0920-1254	Household Representative Questionnaire - Data Collection Instruments (combined English/Spanish)	Attachment 3_COPA Data Collection Instruments_combined 07APR2022.pdf	NA	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 2,700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,700	-20	2,720
Annual IC Time Burden (Hours)	450	-4	454
Annual IC Cost Burden (Dollars)	3,825	533	3,292

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.