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Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English)
[NCEZID] Emerging Infections Program
OMB: 0920-0978
IC ID: 207653
OMB.report
HHS/CDC
OMB 0920-0978
ICR 202302-0920-009
IC 207653
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:
2024-07-26 - Revision of a currently approved collection
2023-12-29 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Form 0920-0978
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English)
Form and Instruction
Form 0920-0978
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English)
Form and Instruction
0920-0978 FluSurv NET Vaccination Phone Script
Att12- FluSurvNet_PhoneScript_English.pdf
Form and Instruction
0920-0978 FluSurv NET Vaccination Phone Script
Att12- FluSurvNet_PhoneScript_English.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Influenza Hospitalization Surveillance Project Vaccination Telephone Script / Consent Form (English)
Agency IC Tracking Number:
0920-0978
Is this a Common Form?
No
IC Status:
Unchanged
Obligation to Respond:
Voluntary
CFR Citation:
42 CFR 301 Public Health Service Act
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
0920-0978
FluSurv NET Vaccination Phone Script
Att12- FluSurvNet_PhoneScript_English.pdf
NA
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
10
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
3,330
0
0
0
0
3,330
Annual IC Time Burden (Hours)
278
0
0
0
0
278
Annual IC Cost Burden (Dollars)
0
0
0
0
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.