Information Collection

Addendum to COVID-19 Data Collection Survey Tool

IC 245831 under ICR 202108-0906-001 · OMB 0906-0062.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Addendum to COVID-19 Data Collection Survey Tool	Form and Instruction
4 ADDENDUM Health Center COVID-19 Vaccine Program FORM 4 - ADDENDUM Health Center COVID-19 Vaccine Program.docx	Form and Instruction
4 ADDENDUM Health Center COVID-19 Vaccine Program FORM 4 - ADDENDUM Health Center COVID-19 Vaccine Program.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	4	ADDENDUM Health Center COVID-19 Vaccine Program	FORM 4 - ADDENDUM Health Center COVID-19 Vaccine Program.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,389

Number of Respondents for Small Entity: 1,389

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	66,672	66,672
Annual IC Time Burden (Hours)	33,336	33,336
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.