Equitable Vaccine Administration Information Submission Template

Public Assistance Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1660-0017 can be found here:

Documents and Forms

Document Name Document Type
Form FEMA Template 104- Equitable Vaccine Administration Information Submission Template Form and Instruction
FEMA Template 104- Equitable Vaccine Response and Recovery: Vaccine Adminis FEMA Template FT-104-FY-21-100_Equitable COVID-19 RR Job Aid_Final.docx www.fema.gov/sites/default/files/documents/fema_public-assistance-covid-19-medical-care-v2-with-equity-job-aid_policy_3- Form and Instruction
FEMA Template 104- Equitable Vaccine Response and Recovery: Vaccine Adminis FEMA Template FT-104-FY-21-100_Equitable COVID-19 RR Job Aid_Final.docx www.fema.gov/sites/default/files/documents/fema_public-assistance-covid-19-medical-care-v2-with-equity-job-aid_policy_3- Form and Instruction

Information Collection (IC) Details

IC Title:	Equitable Vaccine Administration Information Submission Template	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 44 CFR 206

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FEMA Template 104-FY-21-100	Equitable Vaccine Response and Recovery: Vaccine Administration Information	FEMA Template FT-104-FY-21-100_Equitable COVID-19 RR Job Aid_Final.docx	https://www.fema.gov/sites/default/files/documents/fema_public-assistance-covid-19-medical-care-v2-with-equity-job-aid_policy_3-15-2021.pdf	Yes	Yes	Fillable Printable

Line of Business: Disaster Management

Subfunction: Disaster Repair and Restore

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	13,680	13,680
Annual IC Time Burden (Hours)	6,840	6,840
Annual IC Cost Burden (Dollars)	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.