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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.131	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 %

table that charts list of burden
	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

table that charts IC Documents
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.