Information Collection

High Risk Inpatient Influenza Vaccination Numerator Data Form - Method B

IC 183569 under ICR 200801-0920-009 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.75QQ High Risk Inpatient Influenza Vaccination Numerator Data Form - Method B	Form
57.75QQ High Risk Inpatient Influenza Vaccination Numerator Data Part 2 High Risk Inpt Flu Numerator Method B Worksheet.docm	Form

IC Title:

High Risk Inpatient Influenza Vaccination Numerator Data Form - Method B

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.75QQ	High Risk Inpatient Influenza Vaccination Numerator Data Form - Method B	Part 2 High Risk Inpt Flu Numerator Method B Worksheet.docm		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	125,000	125,000
Annual IC Time Burden (Hours)	20,833	20,833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.