Information Collection

COVID-19 Vaccine Survey

IC 244374 under ICR 202003-2900-011 · OMB 2900-0876.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2900-0876-AA2-1 COVID-19 Vaccine Trial VA interaction COVID-19 Vaccine Survey	Form and Instruction
Form 2900-0876-AA2-2 COVID-19 Vaccine Trial Appointment COVID-19 Vaccine Survey	Form and Instruction
Form 2900-0876-AA2-3 COVID-19 Vaccine Trial Study Team COVID-19 Vaccine Survey	Form and Instruction
Form 2900-0876-AA2-4 COVID-19 Vaccine Trial VA.Gov COVID-19 Vaccine Survey	Form and Instruction
2900-0876-AA2-1 COVID-19 Vaccine Trial VA interaction COVID-19 VACCINE TRIAL_EMD 1_V5.A_102920.pdf	Form and Instruction
2900-0876-AA2-2 COVID-19 Vaccine Trial Appointment COVID-19 VACCINE TRIAL_EMD 2_V5.A_102920.pdf	Form and Instruction
2900-0876-AA2-3 COVID-19 Vaccine Trial Study Team COVID-19 VACCINE TRIAL_V5.A_StudyTeam_110320.pdf	Form and Instruction
2900-0876-AA2-4 COVID-19 Vaccine Trial VA.Gov COVID-19 VACCINE TRIAL_VA.GOV_V5.A_102920.pdf	Form and Instruction
A-11 Fast-Track Clearance Request Template_COVID Vaccine.pdf A-11 Fast-Track Clearance Request Template_COVID Vaccine	IC Document
COVID Vaccine Survey Sampling Plan.pdf COVID Vaccine Survey Sampling Plan	IC Document

IC Title:

COVID-19 Vaccine Survey

Agency IC Tracking Number:

2900-0876-AA2

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2900-0876-AA2-1	COVID-19 Vaccine Trial VA interaction	COVID-19 VACCINE TRIAL_EMD 1_V5.A_102920.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AA2-2	COVID-19 Vaccine Trial Appointment	COVID-19 VACCINE TRIAL_EMD 2_V5.A_102920.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AA2-3	COVID-19 Vaccine Trial Study Team	COVID-19 VACCINE TRIAL_V5.A_StudyTeam_110320.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AA2-4	COVID-19 Vaccine Trial VA.Gov	COVID-19 VACCINE TRIAL_VA.GOV_V5.A_102920.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	1,250	1,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
A-11 Fast-Track Clearance Request Template_COVID Vaccine	A-11 Fast-Track Clearance Request Template_COVID Vaccine.pdf	11/03/2020
COVID Vaccine Survey Sampling Plan	COVID Vaccine Survey Sampling Plan.pdf	11/03/2020

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