Information Collection

NIH COVID-19 Vaccination Status Form

IC 249128 under ICR 202203-0925-002 · OMB 0925-0771.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0771 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NIH COVID-19 Vaccination Status Form	Form and Instruction
1 NIHCOVID-19 Vaccination Status Form NIH COVID-19 Vaccination Status Form_Example-Fully-Vaccinated (2).pdf	Form and Instruction
1 NIHCOVID-19 Vaccination Status Form NIH COVID-19 Vaccination Status Form_Example-Fully-Vaccinated (2).pdf	Form and Instruction

IC Title:

NIH COVID-19 Vaccination Status Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	1	NIHCOVID-19 Vaccination Status Form	NIH COVID-19 Vaccination Status Form_Example-Fully-Vaccinated (2).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-25-0166 Radiation and Occupational Safety and Health Management Information Systems, HHS/NIH/ORS

FR Citation: 67 FR 67042

Number of Respondents: 31,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	31,000	31,000
Annual IC Time Burden (Hours)	2,583	2,583
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.