Information Collection

57.204 Healthcare Worker Demographic Data

IC 183579 under ICR 202006-0920-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CDC 57.204 57.204 Healthcare Worker Demographic Data Form
CDC 57.204 Healthcare Worker Demographic Data 57.204_HCWDemographicData_BLANK.docx Form
G12. Healthcare Personnel Exposure.pdf Att G12_HealthCare Personnel Exposure IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.204 Healthcare Worker Demographic Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	CDC 57.204	Healthcare Worker Demographic Data	57.204_HCWDemographicData_BLANK.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	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	Previously Approved
Annual Number of Responses for this IC	10,000	10,000
Annual IC Time Burden (Hours)	3,333	3,333
Annual IC Cost Burden (Dollars)	112,500	112,500

Documents for IC

Title	Document	Date Uploaded
Att G12_HealthCare Personnel Exposure	G12. Healthcare Personnel Exposure.pdf	08/08/2016

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