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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pediatric (5-11 years) COVID-19 Vaccine Screening and Immunization Documentation	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	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 %

	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

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.