Vaccination of Critical Workforce FE, FSE, or Incident

Form Approved

OMB Approval No. 0920-xxxx

Expiration Date: xx/xx/xxxx

Vaccination of Critical Workforce

FE, FSE, or incident

a. Type of vaccine administered (pandemic influenza, seasonal influenza, novel coronavirus, other)

b. Method of vaccine administered (vaccinated, simulated, hybrid)

c. Participating CWG

d. Participating staff vaccinated

e. SMEs involved (select all that apply)

f. SME role

g. Method of notification of targeted CWG

h. Communication platforms used for staff notification

i. Call notification process

Public reporting burden of this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).