Information Collection

Flusurv-net: Provider Pediatric Vaccination History Request Letter/form

IC 231111 under ICR 202406-0920-004 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FSN.300.3 FLUSURV-NET: PROVIDER PEDIATRIC VACCINATION HISTORY REQUEST LETTER/FORM	Form and Instruction
FSN.300.3 FLUSURV-NET: PROVIDER PEDIATRIC VACCINATION HISTORY REQU FSN.300.3 Provider Vaccination History Fax Form.pdf	Form and Instruction
FSN.300.3 FLUSURV-NET: PROVIDER PEDIATRIC VACCINATION HISTORY REQU FSN.300.3 Provider Vaccination History Fax Form.pdf	Form and Instruction

IC Title:

FLUSURV-NET: PROVIDER PEDIATRIC VACCINATION HISTORY REQUEST LETTER/FORM

Agency IC Tracking Number:

0920-0978

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 PHSA

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	FSN.300.3	FLUSURV-NET: PROVIDER PEDIATRIC VACCINATION HISTORY REQUEST LETTER/FORM	FSN.300.3 Provider Vaccination History Fax Form.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13

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	Previously Approved
Annual Number of Responses for this IC	1,638	-126	1,764
Annual IC Time Burden (Hours)	136	-11	147
Annual IC Cost Burden (Dollars)	0	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.