Vaccine Site Data - Outreach to Community Members Form - Booster Vaccines

The HRSA Community Based Outreach Reporting Module

Documents and Forms

Document Name Document Type
Form 4 Vaccine Site Data - Outreach to Community Members Form - Booster Vaccines Form and Instruction
4 Community Based Vaccine Outreach Program Reporting Modul FORM - Community Based Vaccine Outreach Program Reporting Module 09-22-2021.docx Form and Instruction
4 Community Based Vaccine Outreach Program Reporting Modul FORM - Community Based Vaccine Outreach Program Reporting Module 09-22-2021.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Vaccine Site Data - Outreach to Community Members Form - Booster Vaccines	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4	Community Based Vaccine Outreach Program Reporting Module - Booster Vaccines 09-22-2021.docx	FORM - Community Based Vaccine Outreach Program Reporting Module 09-22-2021.docx		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 %

	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

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.