Information Collection

57.209 Healthcare Worker Influenza Vaccination

IC 183548 under ICR 201112-0920-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 57.209 57.209 Healthcare Worker Influenza Vaccination	Form
57.209 Healthcare Worker Influenza Vaccinatuion 57.209_HCWFluVac_BLANK.ppt	Form
5_HPS_fluVacc.pdf 5_HPS_fluVacc	IC Document

IC Title:

57.209 Healthcare Worker Influenza Vaccination

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.209	Healthcare Worker Influenza Vaccinatuion	57.209_HCWFluVac_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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	300,000	300,000
Annual IC Time Burden (Hours)	50,000	50,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
5_HPS_fluVacc	5_HPS_fluVacc.pdf	12/05/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.