Annual Healthcare Personnel Influenza Vaccination Summary (manual)

[NCEZID] The National Healthcare Safety Network (NHSN)

Documents and Forms

Document Name Document Type
Form CDC 57.214 Annual Healthcare Personnel Influenza Vaccination Summary (manual) Form and Instruction
CDC 57.214 Annual Healthcare Personnel Influenza Vaccination Summar 57.214 Healthcare Personnel Influenza Vaccination Summary.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Annual Healthcare Personnel Influenza Vaccination Summary (manual)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 and Instruction	CDC 57.214	Annual Healthcare Personnel Influenza Vaccination Summary	57.214 Healthcare Personnel Influenza Vaccination Summary.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 22,000	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	22,000	17,000	5,000
Annual IC Time Burden (Hours)	44,000	34,000	10,000
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.