REQUEST FOR REPORT OF IMMUNIZATIONS ADMINISTERED

ICR 198405-0915-001

OMB: 0915-0030

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
110087 Migrated
ICR Details
0915-0030 198405-0915-001
Historical Active 198203-0915-001
HHS/HSA
REQUEST FOR REPORT OF IMMUNIZATIONS ADMINISTERED
Extension without change of a currently approved collection   No
Regular
Approved without change 07/13/1984
Retrieve Notice of Action (NOA) 05/18/1984
  Inventory as of this Action Requested Previously Approved
05/31/1987 05/31/1987 05/31/1984
5,000 0 5,000
333 0 333
0 0 0

FORM HSA-468 SOLICITS INFORMATION ON IMMUNIZATIONS ADMINISTERED BY HEALTH PRACTITIONERS. INFORMATION OBTAINED THROUGH THE USE OF THIS FORM WILL BE TRANSCRIBED BY IHS INTO THE PATIENT'S MEDICAL CHART.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR REPORT OF IMMUNIZATIONS ADMINISTERED HSA-468

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 5,000 5,000 0 0 0 0
Annual Time Burden (Hours) 333 333 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
05/18/1984


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