RWHAP MPx Vaccine Distribution Request Table

Ryan White HIV/AIDS Program Mpox Vaccine Distribution

Documents and Forms

Document Name Document Type
Form 1 RWHAP MPx Vaccine Distribution Request Table Form
1 Vaccine Distribution Report Appendix A_RWHAP MPx Vaccine Distribution Request Table.xlsx Form

Information Collection (IC) Details

IC Title:	RWHAP MPx Vaccine Distribution Request Table	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	1	Vaccine Distribution Report	Appendix A_RWHAP MPx Vaccine Distribution Request Table.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 57	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	57	57
Annual IC Time Burden (Hours)	11	11
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.