57.211 Preseason Survey on Influenza Vaccination Program for Healthcare Personnel

The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material.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 57.211 57.211 Preseason Survey on Influenza Vaccination Program for Healthcare Personnel Form
57.211 Pre-season Survey on Influenza Vaccination Programs for 57.211_FluVaccSurveyPRE_BLANK.ppt Form

Information Collection (IC) Details

IC Title:	57.211 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	57.211	Pre-season Survey on Influenza Vaccination Programs for Healthcare Personnel	57.211_FluVaccSurveyPRE_BLANK.ppt		Yes	Yes	Fillable Printable

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	Previously Approved
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	100	100
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.