Information Collection

57.505 Dialysis Patient Influenza Vaccination

IC 208410 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⚠️ Notice: This information collection may be referencing outdated material.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 57.505 57.505 Dialysis Patient Influenza Vaccination	Form
57.505 Dialysis Patient Influenza Vaccination 57.505_Dialysis Patient Flu Vac_BLANK.DOCX	Form
7. Dialysis Patient Influenza Vaccination.pdf 7	IC Document

IC Title:

57.505 Dialysis Patient Influenza Vaccination

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.505	Dialysis Patient Influenza Vaccination	57.505_Dialysis Patient Flu Vac_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: 250

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
Annual Number of Responses for this IC	18,750	18,750
Annual IC Time Burden (Hours)	3,125	3,125
Annual IC Cost Burden (Dollars)	98,375	98,375

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
7	7. Dialysis Patient Influenza Vaccination.pdf	08/22/2013

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