57.210 Healthcare Worker Prophylaxis/Treatment - Influenza

[NCEZID] The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form CDC 57.210 57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Form
CDC 57.210 HCW Prophylaxis/Treatment-Influenza 57.210_HCWFluMedAdmin_BLANK.docx Form
CDC 57.210 HCW Prophylaxis/Treatment-Influenza 57.210_HCWFluMedAdmin_BLANK.docx Form
G12. Healthcare Personnel Exposure.pdf Att G12_Healthcare Personnel Exposure IC Document
G12. Healthcare Personnel Exposure.pdf Att G12_Healthcare Personnel Exposure IC Document

Information Collection (IC) Details

IC Title:	57.210 Healthcare Worker Prophylaxis/Treatment - Influenza	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC 57.210	HCW Prophylaxis/Treatment-Influenza	57.210_HCWFluMedAdmin_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 10 %

	Requested	Previously Approved
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	417	417
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att G12_Healthcare Personnel Exposure	G12. Healthcare Personnel Exposure.pdf	07/25/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.