Provider Forms

National Immunization Survey Evaluation Study

OMB: 0607-0954

IC ID: 188380

Documents and Forms
Document Name
Document Type
Other-Director's Special Sworn Statu
Other-Explanation of the Immunizatio
Other-Frequently Asked Questions abo
Other-2007 Morbidity and Mortality W
Other-Special Sworn Status Reminder
Other-Director's Special Sworn Statu
Other-Director's Immunization Cover
Other-Immunization Reminder Postcard
Other-Director's Immunization Remail
Form
Form
Form
Form
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Provider Forms
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-2007 Morbidity and Mortality Weekly Report Attachment Q 7317-MMWR 2007 OMB 03_25_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 08_07_2009.doc No   Paper Only
Other-Director's Immunization Cover Letter for Providers Attachment T 7317-IMMCL OMB 7_23_2009.doc No   Paper Only
Form 7317-IHQ Immunization History Questionnaire Attachment U 7317-IHQ OMB 8_07_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
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 7_23_2009.doc No   Paper Only
Form 7317-DHAC HIPAA Accounting of Disclosure � Individual Child Attachment Y 7317-DHAC OMB 06_03_2009.doc No   Paper Only
Form 7317-IHQFG Immunization History Quest. Sample for SS Packet Attachment Z 7317-IHQFG OMB 8_07_2009.pdf 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 7317-110S Permission to Contact Immunization Provider ? Spanish Attachment L 7317-110S OMB 06_03_2009.pdf No   Paper Only
Other-Director's Special Sworn Status Cover Letter for Providers Attachment M 7317-SSSCL OMB 08_07_2009.doc 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
Other-Explanation of the Immunization Study Special Sworn Status Attachment O 7317-SSSII OMB 08_07_2009.doc No   Paper Only
Other-Frequently Asked Questions about HIPAA and the NIS Attachment P 7317-FAQ OMB 07_23_2009.doc No   Paper Only

General Government Central Records & Statistical Mgt

 

1,661 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,983 0 0 0 0 4,983
Annual IC Time Burden (Hours) 980 0 0 0 0 980
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.
© 2024 OMB.report | Privacy Policy