Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English)

Emerging Infections Program

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 0920-0978 Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English) Form and Instruction
0920-0978 FluServ-NET Consent Form - English 12- FluSurv-NET Consent Form English.pdf Form and Instruction
0920-0978 FluSurv-NET Vaccination Phone Script (English/Spanish) 15- FluSurv-NET Vaccination Phone Script.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English)	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0978	FluServ-NET Consent Form - English	12- FluSurv-NET Consent Form English.pdf	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0978	FluSurv-NET Vaccination Phone Script (English/Spanish)	15- FluSurv-NET Vaccination Phone Script.pdf	NA	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,330	2,330	1,000
Annual IC Time Burden (Hours)	278	195	83
Annual IC Cost Burden (Dollars)	0	0	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.