Information Collection

Safety event intake form and follow up

IC 207255 under ICR 201306-0935-001 · OMB 0935-0214.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Safety event intake form and follow up	Form and Instruction
Form #1 Intake reporting form - web version Attachment B -- Intake Reporting Form - Web Version.doc	Form and Instruction
Form #2 Intake reporting form - phone version Attachment D -- Intake Reporting Form -- Phone Version.doc	Form and Instruction
Form #3 Intake reporting form follow up Attachment E -- Intake Reporting Form Follow Up.doc	Form and Instruction
Attachment A -- Introductory Pages of Website.docx Attachment A -- Introductory Pages of Website	IC Document
Attachment C -- FAQs List.docx Attachment C -- FAQs List	IC Document
Attachment F -- Marketing Flyer.pdf Attachment F -- Marketing Flyer	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Intake reporting form - web version	Attachment B -- Intake Reporting Form - Web Version.doc	Yes	Yes	Fillable Fileable
Form and Instruction	Form #2	Intake reporting form - phone version	Attachment D -- Intake Reporting Form -- Phone Version.doc	Yes	Yes	Fillable Fileable
Form and Instruction	Form #3	Intake reporting form follow up	Attachment E -- Intake Reporting Form Follow Up.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 840

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	840	840
Annual IC Time Burden (Hours)	490	490
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment A -- Introductory Pages of Website	Attachment A -- Introductory Pages of Website.docx	06/06/2013
Attachment C -- FAQs List	Attachment C -- FAQs List.docx	06/06/2013
Attachment F -- Marketing Flyer	Attachment F -- Marketing Flyer.pdf	06/06/2013

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