57.130 Vaccination Monthly Monitoring Form - Summary Method

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⚠️ Notice: This information collection may be referencing outdated material.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
57.130_VaccMonthlyReportingSummary_BLANK.docx Other-WORD
F1.13PSC_HRIIV.pdf F1 IC Document

Information Collection (IC) Details

IC Title:	57.130 Vaccination Monthly Monitoring Form - Summary Method	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
Other-WORD			57.130_VaccMonthlyReportingSummary_BLANK.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	420,000	420,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
F1	F1.13PSC_HRIIV.pdf	12/05/2011

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