Information Collection

Preseason Survey on Influenza Vaccination Program for Healthcare Personnel

IC 183552 under ICR 200901-0920-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 57.75HH Preseason Survey on Influenza Vaccination Program for Healthcare Personnel Form
57.75HH Preseason Survey on Influenza Vaccination Programs for H HH_FluVaccSurveyPRE.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Preseason Survey on Influenza Vaccination Program for Healthcare Personnel	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	57.75HH	Preseason Survey on Influenza Vaccination Programs for Healthcare Personnel	HH_FluVaccSurveyPRE.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	600	450	150
Annual IC Time Burden (Hours)	100	75	25
Annual IC Cost Burden (Dollars)	0	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.