Information Collection

DoD COVID-19 Vaccine Questionnaire

IC 248153 under ICR 202107-0720-001 · OMB 0720-0069.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0069 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0720-DCVQ-DoD COVID Vaccine Questionnaire 6.11.2021.docx	Other-Questionnaire
0720-DCVQ-DoD COVID Vaccine Questionnaire 6.11.2021.docx	Other-Questionnaire
0720-DCVQ-DoD COVID Vaccine Questionnaire-AudioCARE 6.11.2021.docx	Other-AudioCare System
0720-DCVQ-DoD COVID Vaccine Questionnaire-AudioCARE 6.11.2021.docx	Other-AudioCare System

IC Title:

DoD COVID-19 Vaccine Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Questionnaire			0720-DCVQ-DoD COVID Vaccine Questionnaire 6.11.2021.docx		Yes	Yes	Fillable Fileable
Other-AudioCare System			0720-DCVQ-DoD COVID Vaccine Questionnaire-AudioCARE 6.11.2021.docx		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 570,000

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	570,000	570,000
Annual IC Time Burden (Hours)	19,000	19,000
Annual IC Cost Burden (Dollars)	564,300	564,300

Documents for IC

table that charts IC Documents
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.