COVID-19 Vaccine Screening and Immunization Documentation

ICR 202111-0720-001

OMB: 0720-0068

Federal Form Document

ICR Details
0720-0068 202111-0720-001
Received in OIRA 202106-0720-004
COVID-19 Vaccine Screening and Immunization Documentation
No material or nonsubstantive change to a currently approved collection   No
Regular 11/18/2021
  Requested Previously Approved
08/31/2024 08/31/2024
4,616,000 4,000,000
153,866 666,667
4,840,000 4,840,000

The DHA Form 207, “COVID-19 Vaccine Screening and Immunization Documentation” was approved for ages 12 years and older. The Defense Health Agency (DHA) is now seeking approval for DHA Form 236, “Pediatric COVID-19 Vaccine Screening and Immunization Documentation” for those 5-11 years in order to document the clinical determination if the COVID-19 vaccine is appropriate for the specific patient. The COVID-19 Vaccine Working Group and DHA Patient Safety Office recommended a separate form in order to mitigate possible vaccination errors when administering to children ages 5-11.

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

Not associated with rulemaking

  86 FR 20130 04/16/2021
86 FR 33691 06/25/2021

  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 4,616,000 4,000,000 0 616,000 0 0
Annual Time Burden (Hours) 153,866 666,667 0 -512,801 0 0
Annual Cost Burden (Dollars) 4,840,000 4,840,000 0 0 0 0
Changing Regulations
Miscellaneous Actions
Respondent burden for DHA Form 207 decreased due to updated estimation of number of the respondents. Added DHA 236, collection in use without an OMB Control Number.

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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