HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement

Health Center COVID-19 Vaccine Program

Documents and Forms

Document Name Document Type
Form 1 HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement Form and Instruction
1 HC COVID-19 Vaccine Prgrm Conditions of Participation Ag FORM 1 - HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement 8-16-21.pdf Form and Instruction
1 HC COVID-19 Vaccine Prgrm Conditions of Participation Ag FORM 1 - HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement 8-16-21.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	1	HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement 8-16-21.pdf	FORM 1 - HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement 8-16-21.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,467	Number of Respondents for Small Entity: 1,467

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,467	1,467
Annual IC Time Burden (Hours)	367	367
Annual IC Cost Burden (Dollars)	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.