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57.210 Healthcare Worker Prophylaxis/Treatment - Influenza
[NCEZID] The National Healthcare Safety Network (NHSN)
OMB: 0920-0666
IC ID: 183550
OMB.report
HHS/CDC
OMB 0920-0666
ICR 202410-0920-013
IC 183550
( )
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
G12. Healthcare Personnel Exposure.pdf
Att G12_Healthcare Personnel Exposure
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza
Agency IC Tracking Number:
0920-0666
Is this a Common Form?
No
IC Status:
Removed
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
Federal Enterprise Architecture Business Reference Module
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
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
0
0
-2,500
0
0
2,500
Annual IC Time Burden (Hours)
0
0
-417
0
0
417
Annual IC Cost Burden (Dollars)
0
0
0
0
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.