View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	COVID-19 Vaccine Acceptance	Agency IC Tracking Number:

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 and Instruction	2900-0876-Covid vaccine acceptance survey	2900-0876-Covid vaccine acceptance survey	COVID-19 Vaccine Acceptance Survey Wireframes V3 - 05052021.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	30,000	0	30,000	0	0	0
Annual IC Time Burden (Hours)	1,000	0	1,000	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
A-11 Fast-Track Clearance Request Template_COVID-19 Vaccine Acceptance Survey	A-11 Fast-Track Clearance Request Template_COVID-19 Vaccine Acceptance Survey.pdf	05/12/2021
Recruitment Materials	VSignals Recruiting Materials.pdf	05/13/2021

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