COVID19 Vaccine Perception Surveys (CC)

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIH)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	COVID19 Vaccine Perception Surveys (CC)	Agency IC Tracking Number:

IC Status: New

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	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 %

	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

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.