Information Collection

NIH COVID-19 Vaccine Attestation intake form

IC 249128 under ICR 202108-0925-005 · OMB 0925-0771.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0771 can be found here:

Documents and Forms

Document Name Document Type
Form 1 NIH COVID-19 Vaccine Attestation intake form Form and Instruction
1 NIHCOVID-19 Vaccine Attestation instrument Attachment 1 NIHCOVID-19 Vaccine Attestation instrument.docx Form and Instruction
1 NIHCOVID-19 Vaccine Attestation instrument Attachment 1 NIHCOVID-19 Vaccine Attestation instrument.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NIH COVID-19 Vaccine Attestation intake form	Agency IC Tracking Number:

Is this a Common Form? No		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	1	NIHCOVID-19 Vaccine Attestation instrument	Attachment 1 NIHCOVID-19 Vaccine Attestation instrument.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-25-0166 Radiation and Occupational Safety and Health Management Information Systems, HHS/NIH/ORS	FR Citation: 67 FR 67042

Number of Respondents: 31,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	31,000	31,000
Annual IC Time Burden (Hours)	2,583	2,583
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.