Information Collection

COVID19 Vaccine Perception Surveys (CC)

IC 247230 under ICR 202103-0925-003 · OMB 0925-0648.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 COVID19 Vaccine Perception Surveys (CC)	Form
1 Vaccine survey Vaccine_Survey_For_Vaccine-recipients.pdf	Form
1 Vaccine survey Vaccine_Survey_For_Vaccine-recipients.pdf	Form
CIO Survey Request for COVID Vaccination Site-vaccine-recipients-final (1).docx COVID19 Vaccine Perception Surveys (CC)	IC Document
CIO Survey Request for COVID Vaccination Site-vaccine-recipients-final (1).docx COVID19 Vaccine Perception Surveys (CC)	IC Document
CIO Survey Website for COVID Vaccination Site-vaccine-recipients-final-EMAIL.docx email	IC Document
CIO Survey Website for COVID Vaccination Site-vaccine-recipients-final-EMAIL.docx email	IC Document

IC Title:

COVID19 Vaccine Perception Surveys (CC)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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	1	Vaccine survey	Vaccine_Survey_For_Vaccine-recipients.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,600	3,600
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
COVID19 Vaccine Perception Surveys (CC)	CIO Survey Request for COVID Vaccination Site-vaccine-recipients-final (1).docx	05/06/2021
email	CIO Survey Website for COVID Vaccination Site-vaccine-recipients-final-EMAIL.docx	05/06/2021

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