Screening Questionnaire

NIH COVID-19 Vaccination Status Form

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 2 Screening Questionnaire Form
2 screening questionnaire Attachment 4 Screening Questionnaire.pdf Form
2 screening questionnaire Attachment 4 Screening Questionnaire.pdf Form

Information Collection (IC) Details

IC Title:	Screening Questionnaire	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	2	screening questionnaire	Attachment 4 Screening Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: HHH/NIH/ORS:09-40-0002, Public Health Service (PHS) Commissioned Corps General Personnel Records and OPM/GOVT-10, Employee Medical File System Records.	FR Citation: 81 FR 75138

Number of Respondents: 35,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	35,500	35,500
Annual IC Time Burden (Hours)	2,958	2,958
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.