Information Collection

High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method A

IC 183567 under ICR 200908-0920-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.75PP High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method A Form
57.75PP High Risk Inpatient Influenza Vaccination Monthly Monito PP_PatientFluMonthlyMethodA.ppt Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method A	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	57.75PP	High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method A	PP_PatientFluMonthlyMethodA.ppt		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	480,000	480,000
Annual IC Cost Burden (Dollars)	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.