Information Collection

Provider Forms

IC 188380 under ICR 200903-0607-001 · OMB 0607-0954.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0607-0954 can be found here:

2009-08-12 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment M 7317-SSSCL OMB 04_23_2009.pdf	Other-Director's Special Sworn Statu
Attachment O 7317-SSSII OMB 04_23_2009.pdf	Other-Explanation of the Immunizatio
Attachment P 7317-FAQ OMB 03_25_2009.doc	Other-Frequently Asked Questions abo
Attachment Q 7317-MMWR 2007 OMB 03_25_2009.pdf	Other-2007 Morbidity and Mortality W
Attachment R 7317-SSSP OMB 04_23_2009.pdf	Other-Special Sworn Status Reminder
Attachment S 7317-SSSRL OMB 04_23_2009.pdf	Other-Director's Special Sworn Statu
Attachment T 7317-IMMCL OMB 04_23_2009.pdf	Other-Director's Immunization Cover
Attachment W 7317-IMMP OMB 04_23_2009.pdf	Other-Immunization Reminder Postcard
Attachment X 7317-IMMRL OMB 04_23_2009.pdf	Other-Director's Immunization Remail
7317-110E Permission to Contact Immunization Provider - English Attachment K 7317-110E OMB 06_03_2009.pdf	Form
7317-110S Permission to Contact Immunization Provider ? Spanish Attachment L 7317-110S OMB 06_03_2009.pdf	Form
BC-1759 (P) Immunization Study Special Sworn Status Form Attachment N BC-1759_P_ FINAL OMB 06_03_2009.pdf	Form
7317-IHQ Immunization History Questionnaire Attachment U 7317-IHQ OMB 04_23_2009.pdf	Form
7317-DHA HIPAA Accounting of Disclosure Attachment V - HIPAA Accounting of Disclosure OMB 03_25_2009.doc	Form
7317-DHAC HIPAA Accounting of Disclosure � Individual Child Attachment Y 7317-DHAC OMB 06_03_2009.doc	Form
7317-IHQFG Immunization History Quest. Sample for SS Packet Attachment Z 7371-IHQFG OMB 06_03_2009.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Provider Forms

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	Available Electronically?	Electronic Capability
Other-Frequently Asked Questions about HIPAA and the NIS			Attachment P 7317-FAQ OMB 03_25_2009.doc	No	Paper Only
Other-2007 Morbidity and Mortality Weekly Report			Attachment Q 7317-MMWR 2007 OMB 03_25_2009.pdf	No	Paper Only
Form	7317-DHA	HIPAA Accounting of Disclosure	Attachment V - HIPAA Accounting of Disclosure OMB 03_25_2009.doc	No	Paper Only
Form	7317-110E	Permission to Contact Immunization Provider - English	Attachment K 7317-110E OMB 06_03_2009.pdf	No	Paper Only
Form	7317-IHQFG	Immunization History Quest. Sample for SS Packet	Attachment Z 7371-IHQFG OMB 06_03_2009.pdf	No	Paper Only
Form	7317-110S	Permission to Contact Immunization Provider ? Spanish	Attachment L 7317-110S OMB 06_03_2009.pdf	No	Paper Only
Form	BC-1759 (P)	Immunization Study Special Sworn Status Form	Attachment N BC-1759_P_ FINAL OMB 06_03_2009.pdf	No	Paper Only
Form	7317-DHAC	HIPAA Accounting of Disclosure ï¿½ Individual Child	Attachment Y 7317-DHAC OMB 06_03_2009.doc	No	Paper Only
Other-Immunization Reminder Postcard			Attachment W 7317-IMMP OMB 04_23_2009.pdf	No	Paper Only
Other-Director's Immunization Remail Letter for Providers			Attachment X 7317-IMMRL OMB 04_23_2009.pdf	No	Paper Only
Other-Director's Immunization Cover Letter for Providers			Attachment T 7317-IMMCL OMB 04_23_2009.pdf	No	Paper Only
Form	7317-IHQ	Immunization History Questionnaire	Attachment U 7317-IHQ OMB 04_23_2009.pdf	No	Paper Only
Other-Explanation of the Immunization Study Special Sworn Status			Attachment O 7317-SSSII OMB 04_23_2009.pdf	No	Paper Only
Other-Special Sworn Status Reminder Postcard			Attachment R 7317-SSSP OMB 04_23_2009.pdf	No	Paper Only
Other-Director's Special Sworn Status Remail Letter for Providers			Attachment S 7317-SSSRL OMB 04_23_2009.pdf	No	Paper Only
Other-Director's Special Sworn Status Cover Letter for Providers			Attachment M 7317-SSSCL OMB 04_23_2009.pdf	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,661

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	4,983	4,983
Annual IC Time Burden (Hours)	980	980
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.