NIH COVID-19 Vaccination Status Form

Forms and Documents

Document Name	Status
Form 1 NIH COVID-19 Vaccination Status Form Form and Instruction	Modified
0925-0771 OMB Change Request Memo.docx Justification for No Material/Nonsubstantive Change	2021-10-04
emergency FRN2021-18636.pdf Supplementary Document	2021-08-31
PiaFrm_Privacy Module NSAT Annual Review Submited AA_2021.rtf Supplementary Document	2021-08-31
PIA - NIDDK On-Site Web and Apps 8-4-2021.pdf Supplementary Document	2021-08-31
Support_Statement A_NIHCOVID-19 Vaccine Attestation intake form 2021-08-31.docx Supporting Statement A	2021-08-31

IC Document Collections

IC ID	Document Title	Status
249128	NIH COVID-19 Vaccination Status Form Form and Instruction	Modified

ICR Details

OMB Control No: 0925-0771	ICR Reference No: 202110-0925-001
Status: Received in OIRA	Previous ICR Reference No: 202108-0925-005
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: NIH COVID-19 Vaccination Status Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 09/09/2021
Date Submitted to OIRA: 10/05/2021

	Requested	Previously Approved
Expiration Date	03/31/2022	03/31/2022
Responses	31,000	31,000
Time Burden (Hours)	2,583	2,583
Cost Burden (Dollars)	0	0

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Abstract: 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.

Emergency Justfication: 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.

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Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Safer Federal Workforce Task Force
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

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

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ICR Summary of Burden

	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

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $122,137

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

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Common Form ICR:  No

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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: 10/05/2021

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