Information Collection

RWHAP MPx Vaccine Distribution Request Table

IC 261183 under ICR 202307-0915-004 · OMB 0915-0395.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 RWHAP MPx Vaccine Distribution Request Table	Form
1 Vaccine Distribution Report Appendix A_RWHAP MPx Vaccine Distribution Request Table.xlsx	Form
1 Vaccine Distribution Report Appendix A_RWHAP MPx Vaccine Distribution Request Table.xlsx	Form

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Vaccine Distribution Report	Appendix A_RWHAP MPx Vaccine Distribution Request Table.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 57

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	57	57
Annual IC Time Burden (Hours)	11	11
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.