NIH COVID-19 Vaccination Status Form

ICR 202110-0925-001

OMB: 0925-0771

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2021-10-04
Supplementary Document
2021-08-31
Supplementary Document
2021-08-31
Supplementary Document
2021-08-31
Supporting Statement A
2021-08-31
IC Document Collections
IC ID
Document
Title
Status
249128 Modified
ICR Details
0925-0771 202110-0925-001
Received in OIRA 202108-0925-005
HHS/NIH
NIH COVID-19 Vaccination Status Form
No material or nonsubstantive change to a currently approved collection   No
Emergency 09/09/2021
10/05/2021
  Requested Previously Approved
03/31/2022 03/31/2022
31,000 31,000
2,583 2,583
0 0

The NIH now has a mandatory vaccination requirement that affects several thousand staff. We have been providing contractors, tenants, fellows and other staff access to testing and vaccines during this pandemic. The information to be collected is needed to ensure we have the vaccination details for our staff to properly offer booster shots, and to match original shot provided (if required). This information is also critical so we can plan which vaccines we need to have on hand for booster administration to staff. We are not yet sure if the vaccines will be interchangeable. Knowing the manufacturer will allow us to plan and administer in a proactive way, ensuring compliance with EUA and medical requirements.
The NIH now has a mandatory vaccination requirement that affects several thousand staff. We have been providing contractors, tenants, fellows and other staff access to testing and vaccines during this pandemic. The information to be collected is needed to ensure we have the vaccination details for our staff to properly offer booster shots, and to match original shot provided (if required). This information is also critical so we can plan which vaccines we need to have on hand for booster administration to staff. We are not yet sure if the vaccines will be interchangeable. Knowing the manufacturer will allow us to plan and administer in a proactive way, ensuring compliance with EUA and medical requirements. All this information will flow into our electronic health information system and become part of their OMS record, similar to the influenza program we also administer. The dates included in this form will allow us to ensure equitable scheduling in order with the timeframe in which the original vaccination was administered. The information on the boosters is that they will be due 8 months after initial dose series completion. Without this information we cannot schedule in an equitable manner for those vaccinated within the community, even if they are subject to the mandatory requirements and work on site daily. We are including a check box for medical or religious declination and an uploaded signature page, consistent with the mandatory policy mirroring the one we currently have in place for influenza.

EO: EO 13991 Name/Subject of EO: Safer Federal Workforce Task Force
  
None

Not associated with rulemaking

No

1
IC Title Form No. Form Name
NIH COVID-19 Vaccination Status Form 1 NIHCOVID-19 Vaccination Status Form

  Total Request 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 31,000 31,000 0 0 0 0
Annual Time Burden (Hours) 2,583 2,583 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$122,137
No
    Yes
    Yes
No
No
No
Yes
Mikia Currie 3014350941

  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:
 
 
 
 
 
 
 
    (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.
10/05/2021


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