Information Collection

57.210 Healthcare Worker Prophylaxis/Treatment - Influenza

IC 183550 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form
57.210 Healthcare Worker Prophylaxis/Treatment Influenza 57.210_HCWFluMedAdmin_BLANK.ppt Form
5_HPS_fluVacc.pdf 5_HPS_fluVacc IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	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	57.210	Healthcare Worker Prophylaxis/Treatment Influenza	57.210_HCWFluMedAdmin_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	30,000	30,000
Annual IC Time Burden (Hours)	5,000	5,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.