Information Collection

Pediatric (5-11 years) COVID-19 Vaccine Screening and Immunization Documentation

IC 250385 under ICR 202111-0720-001 · OMB 0720-0068.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 236 Pediatric (5-11 years) COVID-19 Vaccine Screening and Immunization Documentation	Form and Instruction
236 Pediatric (5-11 years) COVID-19 Vaccine Screening and Im DHA 236.pdf	Form and Instruction
236 Pediatric (5-11 years) COVID-19 Vaccine Screening and Im DHA 236.pdf	Form and Instruction

IC Title:

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
Form and Instruction	236	Pediatric (5-11 years) COVID-19 Vaccine Screening and Immunization Documentation	DHA 236.pdf		Yes	Yes	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 308,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	616,000	616,000
Annual IC Time Burden (Hours)	20,533	20,533
Annual IC Cost Burden (Dollars)	0	0

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.