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

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 can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
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 completed the 18-month Follow-up Survey Form and Instruction
18-month Follow-up Survey for Z-CAN patients 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 completed the 18-month Follow-up Survey Form and Instruction
18-month Follow-up Survey for Z-CAN patients Form and Instruction

All Historical Document Collections

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

OMB Details

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

Federal Enterprise Architecture: Disaster Management - Emergency Response

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.