Information Collection

Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)

IC 270309 under ICR 202410-0920-012 · OMB 0920-1317.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1317 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)	Form and Instruction
57.216 Optional Person Level Reporting of Weekly COVID-19 Vacci 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents.docx	Form and Instruction
57.216 Optional Person Level Reporting of Weekly COVID-19 Vacci 57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents.docx	Form and Instruction

IC Title:

Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents (manual)

Agency IC Tracking Number:

0920-1317

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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	57.216	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents	57.216 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Long-Term Care Residents.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,669

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

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	86,788	0	86,788
Annual IC Time Burden (Hours)	89,681	2,893	86,788
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.