Information Collection

57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual

IC 249436 under ICR 202602-0920-005 · OMB 0920-1317.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients_Manual 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual	Form and Instruction
Form 57.509 57.509 - Weekly COVID-19 Vaccination Cumulative Summary for Dialysis Patients - 11FEB2026 57.509 Weekly Patient COVID-19 Vaccination Cumulative Summary for Dialysis Facilities_Manual	Form and Instruction
57.509 Weekly COVID-19 Vaccination Cumulative Summary for Dialy COVIDVax.Dialysis.FORM_September2021_ARB.EK.docx	Form and Instruction
57.509 57.509 - Weekly COVID-19 Vaccination Cumulative Summary 57.509 Weekly Patient COVID-19 Vaccination Summary.Dialysis Facilities.September 2025.Clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1317

Is this a Common Form? No

IC Status: Modified

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	57.509			NA	Yes	Yes	Fillable Fileable
Form and Instruction	57.509			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: 107

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
	Requested	Previously Approved
Annual Number of Responses for this IC	1,284	1,284
Annual IC Time Burden (Hours)	963	963
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.

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