Information Collection

57.210 Healthcare Worker Prophylaxis/Treatment - Influenza

IC 183550 under ICR 201211-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form
57.210 Healthcare Worker Prophylaxis/Treatment Influenza 57.210_HCWFluMedAdmin_BLANK.ppt	Form
7. Healthcare Personnel Safety Component (IC#s 3, 9, 16, 34, 35, 36, 38).pdf Att G.7 HPSC	IC Document

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.210	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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Att G.7 HPSC	7. Healthcare Personnel Safety Component (IC#s 3, 9, 16, 34, 35, 36, 38).pdf	10/15/2012

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