Information Collection

Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults)

IC 231111 under ICR 201902-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0978 Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults)	Form and Instruction
0920-0978 FluSurv Net Provider Vaccination History Fax Form Att 12- FluSurv-NET Provider Vaccination History Fax Form.pdf	Form and Instruction

IC Title:

Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 PHSA

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 and Instruction	0920-0978	FluSurv Net Provider Vaccination History Fax Form	Att 12- FluSurv-NET Provider Vaccination History Fax Form.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

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
	Approved	Previously Approved
Annual Number of Responses for this IC	3,330	3,330
Annual IC Time Burden (Hours)	278	278
Annual IC Cost Burden (Dollars)	0	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.