Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)

[NCEZID] National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities

⚠️ Notice: This information collection may be referencing outdated material.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 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction
Form 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual) Form and Instruction
57.217 Optional Person Level Reporting of Weekly COVID-19 Vacci 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel.docx Form and Instruction
57.217 Optional Person Level Reporting of Weekly COVID-19 Vacci 57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel (manual)	Agency IC Tracking Number:	0920-1317

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	57.217	Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel	57.217 Optional Person Level Reporting of Weekly COVID-19 Vaccination for Healthcare Personnel.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 96	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,992	4,992
Annual IC Time Burden (Hours)	4,992	4,992
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.