COVID-19 Vaccine Screening and Immunization Documentation DHA Form 207

ICR 202101-0720-001

OMB: 0720-0068

Federal Form Document

IC Document Collections
ICR Details
0720-0068 202101-0720-001
COVID-19 Vaccine Screening and Immunization Documentation DHA Form 207
New collection (Request for a new OMB Control Number)   No
Emergency 01/18/2021
Approved without change 01/13/2021
Retrieve Notice of Action (NOA) 01/13/2021
  Inventory as of this Action Requested Previously Approved
07/31/2021 6 Months From Approved
9,000,000 0 0
1,500,000 0 0
10,890,000 0 0

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.
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.

US Code: 10 USC 55 Name of Law: Medical and Dental Care

Not associated with rulemaking


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

  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
Miscellaneous Actions
This is a new collection requirement with a new associated burden.

Kira Starks 571 372-4529 [email protected]


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:
    (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;
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.

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