OMB control number

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

OMB 0920-1241 · HHS/CDC.

OMB 0920-1241

The purpose of this project is to assess the implementation and associated outcomes of the Zika Contraception Access Network (Z-CAN), an initiative that provided patient-centered services to reproductive-aged women in Puerto Rico who chose to delay or avoid pregnancy while local Zika virus transmission was ongoing. This Non-Substantive Change is being requested to increase the value of the gift card given to women who participate in the 18- and 30-month follow-up surveys as a token of appreciation from $5 to $10 as means to improve participation. The requested change does not affect any other component of the information collection.

The latest form for Assessment of a Preventive Service Program in the Context of a Zika Virus Outbreak in Puerto Rico expires 2020-08-31 and is listed under ICR 201902-0920-017.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Screenshots of the 30-month Follow-up Survey (Version B for Z-CAN patients who did not complete the 18-month Follow-up Survey)	Form and Instruction
Screenshots of the 30-month Follow-up Survey (Version A for Z-CAN patients who completed the 18-month Follow-up Survey)	Form and Instruction
Screenshots of the 18-month Follow-up Survery for Z-CAN patients ages 18+	Form and Instruction
0920-1241 Change Request Justification 2-15-2019.docx	Justification for No Material/Nonsubstantive Change
Att I Referenced articles.pdf	Supplementary Document
Att G Consent_Online Survey_18_30_ZCAN women (Eng and Span).docx	Supplementary Document
Att F Invitation_Online Survey_18_30_ZCAN women (Eng and Span).docx	Supplementary Document
Att E Interim contacts with ZCAN women (Eng and Span).docx	Supplementary Document
Att D-2 UPR IRB approval letter.pdf	Supplementary Document
Att D-1 CDC IRB approval letter.pdf	Supplementary Document
Att C Privacy Act Determination.pdf	Supplementary Document
Att B-1 60-day FRN March 30 2018.pdf	Supplementary Document
Att A-Section 301 of the PHS Act.pdf	Supplementary Document
SSB_Z-CAN_07022018.docx	Supporting Statement B
SSA_Z-CAN_07022018.docx	Supporting Statement A
30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey	Form and Instruction
30-month Follow-up Survey for Z-CAN patients who did not complete the 18-month Follow-up Survey	Other-Word version of survey content for reference/editing (Engl
30-month Follow-up Survey for Z-CAN patients who completed the 18-month Follow-up Survey	Form and Instruction
30-month Follow-up Survey for Z-CAN patients who completed the 18-month Follow-up Survey	Other-Word version of survey content for reference/editing (Engl
18-month Follow-up Survey for Z-CAN patients	Form and Instruction
18-month Follow-up Survey for Z-CAN patients	Other-Word version of survey content for reference/editing (Engl

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Concluded	Action
201902-0920-017	No material or nonsubstantive change to a currently approved collection	2019-02-26		Approved without change
201806-0920-010	New collection (Request for a new OMB Control Number)	2018-07-23		Approved without change

OMB Details

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

Federal Enterprise Architecture: Disaster Management - Emergency Response

Information collection instruments
Form	Name	Electronic access	Type
Form n/a	Screenshots of the 18-month Follow-up Survery for Z-CAN patients ages 18+	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.