Information Collection

57.131 High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B

IC 183571 under ICR 201105-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.131 57.131 High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B Form
57.131 Vaccination Monthkly Monitoring Form-Patient-Level Metho 57.131_VaccMonthlyReportingPatient_BLANK.ppt Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.131 High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B	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	57.131	Vaccination Monthkly Monitoring Form-Patient-Level Method	57.131_VaccMonthlyReportingPatient_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: 2,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,000	0	10,000
Annual IC Time Burden (Hours)	20,000	-20,000	40,000
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.