Information Collection

57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual

IC 271945 under ICR 202501-0920-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual Form and Instruction
57.221 Healthcare Personnel COVID-19 Person Level Vaccination-L 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_Manual.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component _Manual	Agency IC Tracking Number:	0920-1317

Is this a Common Form? No		IC Status: Unchanged

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	57.221	Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_Manual	57.221 Healthcare Personnel COVID-19 Person Level Vaccination-LTC Component_Manual.docx	N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 73	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,796	3,796
Annual IC Time Burden (Hours)	3,796	3,796
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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