Information Collection

57.131 Vaccination Monthly Monitoring Form - Patient-Level Method

IC 183571 under ICR 201308-0920-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.131 57.131 Vaccination Monthly Monitoring Form - Patient-Level Method Form
57.131 Vaccination Monthly Monitoring - Patient level 57.131_VaccMonthlyReportingPatient_BLANK.DOCX Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.131 Vaccination Monthly Monitoring Form - Patient-Level 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
Form	57.131	Vaccination Monthly Monitoring - Patient level	57.131_VaccMonthlyReportingPatient_BLANK.DOCX		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	-9,500	10,000
Annual IC Time Burden (Hours)	1,000	-19,000	20,000
Annual IC Cost Burden (Dollars)	37,840	37,840	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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