Information Collection

57.505 Dialysis Patient Influenza Vaccination

IC 208410 under ICR 202212-0920-013 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC 57.505 57.505 Dialysis Patient Influenza Vaccination	Form
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.