Information Collection

57.208 Healthcare Worker Vaccination History

IC 183580 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 57.208 57.208 Healthcare Worker Vaccination History Form
57.208 Healthcare Worker Vaccination History 57.208_HCWVaccHistory_BLANK.ppt Form
5_HPS_fluVacc.pdf 5_HPS_fluVacc IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.208 Healthcare Worker Vaccination History	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	57.208	Healthcare Worker Vaccination History	57.208_HCWVaccHistory_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 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-180,000	180,000
Annual IC Time Burden (Hours)	-30,000	30,000
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.