Information Collection

Equitable Vaccine Administration Information Submission Template

IC 247457 under ICR 202402-1660-004 · OMB 1660-0017.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 44 CFR 206

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 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: DHS/FEMA-009-Hazard Mitigation, Disaster Public Assistance, and Disaster Loan Programs System of Records

FR Citation: 79 FR 16015

Number of Respondents: 60

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	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

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.