Information Collection

57.210 Healthcare Worker Prophylaxis/Treatment - Influenza

IC 183550 under ICR 202301-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Form
CDC 57.210 HCW Prophylaxis/Treatment-Influenza 57.210_HCWFluMedAdmin_BLANK.docx	Form
CDC 57.210 HCW Prophylaxis/Treatment-Influenza 57.210_HCWFluMedAdmin_BLANK.docx	Form
G12. Healthcare Personnel Exposure.pdf Att G12_Healthcare Personnel Exposure	IC Document
G12. Healthcare Personnel Exposure.pdf Att G12_Healthcare Personnel Exposure	IC Document

IC Title:

57.210 Healthcare Worker Prophylaxis/Treatment - Influenza

Agency IC Tracking Number:

0920-0666

Is this a Common Form? No

IC Status: Modified

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 57.210	HCW Prophylaxis/Treatment-Influenza	57.210_HCWFluMedAdmin_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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: 10 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,500	0	2,500
Annual IC Time Burden (Hours)	417	0	417
Annual IC Cost Burden (Dollars)	0	-14,063	14,063

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att G12_Healthcare Personnel Exposure	G12. Healthcare Personnel Exposure.pdf	07/25/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.