57.505 Dialysis Patient Influenza Vaccination

The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material.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 57.505 57.505 Dialysis Patient Influenza Vaccination Form
CDC 57.505 Dialysis Patient Influenza Vaccination 57.505_DIAL Pt Flu Vacc_BLANK.docx Form
CDC 57.505 Dialysis Patient Influenza Vaccination 57.505_DIAL Pt Flu Vacc_BLANK.docx Form
G10. Dialysis Patient Influenza Vaccination.pdf Att G10_Dialysis Patient Influenza Vaccination IC Document
G10. Dialysis Patient Influenza Vaccination.pdf Att G10_Dialysis Patient Influenza Vaccination IC Document

Information Collection (IC) Details

IC Title:	57.505 Dialysis Patient Influenza Vaccination	Agency IC Tracking Number:	0920-0666

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 57.505	Dialysis Patient Influenza Vaccination	57.505_DIAL Pt Flu Vacc_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: 615	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	30,750	30,750
Annual IC Time Burden (Hours)	5,125	5,125
Annual IC Cost Burden (Dollars)	166,296	166,296

Documents for IC

Title	Document	Date Uploaded
Att G10_Dialysis Patient Influenza Vaccination	G10. Dialysis Patient Influenza Vaccination.pdf	08/08/2016

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