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Vaccine Site Data - Outreach to Community Members Form - Booster Vaccines
The HRSA Community Based Outreach Reporting Module
OMB: 0906-0064
IC ID: 249594
OMB.report
HHS/HRSA
OMB 0906-0064
ICR 202109-0906-002
IC 249594
( )
Documents and Forms
Document Name
Document Type
Form 4
Vaccine Site Data - Outreach to Community Members Form - Booster Vaccines
Form and Instruction
4 Community Based Vaccine Outreach Program Reporting Modul
FORM - Community Based Vaccine Outreach Program Reporting Module 09-22-2021.docx
Form and Instruction
4 Community Based Vaccine Outreach Program Reporting Modul
FORM - Community Based Vaccine Outreach Program Reporting Module 09-22-2021.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Vaccine Site Data - Outreach to Community Members Form - Booster Vaccines
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
4
Community Based Vaccine Outreach Program Reporting Module - Booster Vaccines 09-22-2021.docx
FORM - Community Based Vaccine Outreach Program Reporting Module 09-22-2021.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
4,000,000
Number of Respondents for Small Entity:
141
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
4,000,000
0
4,000,000
0
0
0
Annual IC Time Burden (Hours)
466,667
0
466,667
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
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.