Information Collection

Vaccine Site Data - Outreach to Community Members Form

IC 248291 under ICR 202107-0906-001 · OMB 0906-0064.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0064 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Vaccine Site Data - Outreach to Community Members Form	Form and Instruction
2 Vaccine Site Data - Outreach to Community Members Form Community Based Vaccine Outreach Program Reporting Module 07-07-2021.docx www.surveymonkey.com/r/ZJ8PQCX	Form and Instruction

IC Title:

Vaccine Site Data - Outreach to Community Members Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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 and Instruction	2	Vaccine Site Data - Outreach to Community Members Form	Community Based Vaccine Outreach Program Reporting Module 07-07-2021.docx	https://www.surveymonkey.com/r/ZJ8PQCX	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000,000

Number of Respondents for Small Entity: 141

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000,000	4,000,000
Annual IC Time Burden (Hours)	466,667	466,667
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.