Information Collection

Call-back Survey and Consent

IC 228432 under ICR 201708-0920-024 · OMB 0920-1212.

Documents and Forms

Document Name Document Type
Call-back Survey and Consent Form and Instruction
Zika Reproductive Health Call-Back Survey (ZRHCS), Puert Att 4 ZRHCS Survey and Consent.DOCX Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Call-back Survey and Consent	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	NA	Zika Reproductive Health Call-Back Survey (ZRHCS), Puerto Rico, 2017 - Survey and Consent	Att 4 ZRHCS Survey and Consent.DOCX	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 581	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
Annual Number of Responses for this IC	581	581
Annual IC Time Burden (Hours)	97	97
Annual IC Cost Burden (Dollars)	0	0

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.