Information Collection

Att 6_2014-15 Vaccination History Patient/Proxy Interview

IC 207653 under ICR 201501-0920-018 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Document Name Document Type
Att 6_2014-15 Vaccination History Patient/Proxy Interview Form
Att 6_2014-15 Vaccination History Patient/Proxy Intervie Attachment 06_2014-15 Vaccination Telephone Surveys (English).pdf Form
Attachment 07_2014-15 Vaccination Telephone Surveys (Spanish).pdf Att 7_Vaccination History Patient/Proxy Interview (Spanish) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att 6_2014-15 Vaccination History Patient/Proxy Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Att 6_2014-15 Vaccination History Patient/Proxy Interview (English)	Attachment 06_2014-15 Vaccination Telephone Surveys (English).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 7_Vaccination History Patient/Proxy Interview (Spanish)	Attachment 07_2014-15 Vaccination Telephone Surveys (Spanish).pdf	01/16/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.