57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual

[NCEZID] National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities

Documents and Forms

Document Name Document Type
Form 57.509 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual Form and Instruction
57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialy COVIDVax.Dialysis.FORM_September2021_ARB.EK.docx Form and Instruction

Information Collection (IC) Details

IC Title:	57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual	Agency IC Tracking Number:	0920-1317

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	57.509	Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_Manual	COVIDVax.Dialysis.FORM_September2021_ARB.EK.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 107	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: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,284	-399,116	400,400
Annual IC Time Burden (Hours)	963	-499,537	500,500
Annual IC Cost Burden (Dollars)	0	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.