Addendum to COVID-19 Data Collection Survey Tool

Health Center COVID-19 Vaccine Program

Documents and Forms

Document Name Document Type
Form 4 Addendum to COVID-19 Data Collection Survey Tool Form and Instruction
4 ADDENDUM Health Center COVID-19 Vaccine Program FORM 4 - ADDENDUM Health Center COVID-19 Vaccine Program.docx Form and Instruction
4 ADDENDUM Health Center COVID-19 Vaccine Program FORM 4 - ADDENDUM Health Center COVID-19 Vaccine Program.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Addendum to COVID-19 Data Collection Survey Tool	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	ADDENDUM Health Center COVID-19 Vaccine Program	FORM 4 - ADDENDUM Health Center COVID-19 Vaccine Program.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,389	Number of Respondents for Small Entity: 1,389

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	66,672	66,672
Annual IC Time Burden (Hours)	33,336	33,336
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.