Information Collection

57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV

IC 271948 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV	Form and Instruction
57.221 57.221 Healthcare Personnel COVID-19 Person Level Vaccin 57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Personnel Safety_CSV.docx	Form and Instruction

IC Title:

57.221 Healthcare Personnel COVID-19 Person Level Vaccination-Healthcare Personnel Safety Component_CSV

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

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	57.221			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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	876	876
Annual IC Time Burden (Hours)	584	584
Annual IC Cost Burden (Dollars)	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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].