| GrantNumber |
Recipient Name |
Recipient Point of Contact (POC) Name |
Recipient POC Contact Information (email/phone number) |
Recipient interested in receiving vaccine vials (Yes/No) |
Number of boxes (each box contains 20 vials) being requested (there is not a predetermined number) |
Shipment POC Name, if different from Recipient POC |
Shipment POC Contact Information, if different from Recipient POC (email/phone number) |
Shipment Address (Street Address, City, State, and Zipcode) |
Signed doc/assurance returned |
| Public Burden Statement: The purpose of this collection is to collect JYNNEOS vaccine administration and inventory/wastage data from Ryan White HIV/AIDS Program recipients receiving shipments of the JYNNEOS vaccine. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-XXXX and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (Public Law 111 – 352, Section 4). Public reporting burden for this collection of information is estimated to average 0.23 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov. |
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