Annual Healthcare Personnel Influenza Vaccination Summary (CSV)

[NCEZID] The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form 57.214 Annual Healthcare Personnel Influenza Vaccination Summary (CSV) Form
57.214 CSV Submission 57.214 CSV Submission.docx Form
57.214 CSV Submission 57.214 CSV Submission.docx Form

Information Collection (IC) Details

IC Title:	Annual Healthcare Personnel Influenza Vaccination Summary (CSV)	Agency IC Tracking Number:

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	57.214	CSV Submission	57.214 CSV Submission.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,920	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 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,920	-20,080	22,000
Annual IC Time Burden (Hours)	1,760	-42,240	44,000
Annual IC Cost Burden (Dollars)	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.