Information Collection

Att 6_2014-15 Vaccination History Patient/Proxy Interview

IC 207653 under ICR 201501-0920-018 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 6_2014-15 Vaccination History Patient/Proxy Interview	Form
Att 6_2014-15 Vaccination History Patient/Proxy Intervie Attachment 06_2014-15 Vaccination Telephone Surveys (English).pdf	Form
Attachment 07_2014-15 Vaccination Telephone Surveys (Spanish).pdf Att 7_Vaccination History Patient/Proxy Interview (Spanish)	IC Document

IC Title:

Att 6_2014-15 Vaccination History Patient/Proxy Interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

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	none	Att 6_2014-15 Vaccination History Patient/Proxy Interview (English)	Attachment 06_2014-15 Vaccination Telephone Surveys (English).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 7_Vaccination History Patient/Proxy Interview (Spanish)	Attachment 07_2014-15 Vaccination Telephone Surveys (Spanish).pdf	01/16/2015

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