COVID-19 Vaccine Screening and Immunization Documentation DHA Form 207

Forms and Documents

Document Name	Status
Form 207 COVID-19 Vaccine Screening and Immunization Documentation Form and Instruction	New
Reply to HHS comments Covid-19 Screening Docummentation Form 12 Jan.docx Supplementary Document	2021-01-13
IHD Response to CDC comments.pdf Supplementary Document	2021-01-13
0720-VSID_SS-A_12.13.2021.docx Supporting Statement A	2021-01-13
Pfizer-BioNTECH COVID-19 Vaccine EUA Fact sheet for Recipients revised 12-23-20.pdf Supplementary Document	2021-01-13
0397469 Coronavirus Disease 2019 Vaccine Guidance (OSD011566-20) eligibility.pdf Supplementary Document	2021-01-13

IC Document Collections

IC ID	Document Title	Status
245326	COVID-19 Vaccine Screening and Immunization Documentation Form and Instruction	New

ICR Details

OMB Control No: 0720-0068	ICR Reference No: 202101-0720-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-VSID
Title: COVID-19 Vaccine Screening and Immunization Documentation DHA Form 207
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 01/18/2021
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/13/2021
	Date Received in OIRA: 01/13/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2021	6 Months From Approved
Responses	9,000,000	0	0
Time Burden (Hours)	1,500,000	0	0
Cost Burden (Dollars)	10,890,000	0	0

---

Abstract: The Defense Health Agency (DHA) has created the DHA Form 207, “COVID-19 Vaccine Screening and Immunization Documentation” to determine if the COVID-19 vaccine can be administered to a patient. The DHA Form 207 will be used to determine and document patient eligibility and vaccine declinations for a COVID-19 vaccination. Respondents include Active Duty military members, Federal employees, beneficiaries, and contractors (based on their employment) who wish to receive the vaccine.

Emergency Justfication: DHA Form 207 is needed for immediate use to respond to the ongoing COVID-19 pandemic and vaccinate personnel critical to the Department of Defense's mission and national security.

---

Authorizing Statute(s): US Code: 10 USC 55 Name of Law: Medical and Dental Care
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
COVID-19 Vaccine Screening and Immunization Documentation	207	COVID-19 Vaccine Screening and Immunization Documentation

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	9,000,000	0	0	9,000,000	0	0
Annual Time Burden (Hours)	1,500,000	0	0	1,500,000	0	0
Annual Cost Burden (Dollars)	10,890,000	0	0	10,890,000	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection requirement with a new associated burden.

---

Annual Cost to Federal Government: $73,102,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/13/2021

---