57.506 Dialysis Patient Influenza Vaccination Denominator

The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material.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 57.506 57.506 Dialysis Patient Influenza Vaccination Denominator Form
57.506 Dialysis Patient Influenza Vaccination Denominator 57.506_Dialysis Patient Flu Vac Denom_BLANK.DOCX Form

Information Collection (IC) Details

IC Title:	57.506 Dialysis Patient Influenza Vaccination Denominator	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	57.506	Dialysis Patient Influenza Vaccination Denominator	57.506_Dialysis Patient Flu Vac Denom_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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,250	1,250
Annual IC Time Burden (Hours)	208	208
Annual IC Cost Burden (Dollars)	6,558	6,558

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.