1 NIH COVID-19 Vaccination Status Form

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COVID-19 Vaccination Status Form

Privacy Act Statement
This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. § 552a): The information requested in the
COVID-19 Case Management System is authorized to be collected pursuant to NIH Policy Manual 0004 NIH COVID-19
Vaccination Policy for Healthcare Workforce, Department of Health and Human Services (HHS) memo (Aug. 6, 2021),
Policy to Require COVID-19 Vaccinations for Certain HHS Employees and Other Staff, section 402 of the Public Health
Service Act, the Office of Personnel Management (OPM) regulation 5 C.F.R. § 339.205, Executive Order 13991,
Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), Executive Order 12196, Occupational
Safety and Health Program for Federal Employees (Feb. 26, 1980), and 5 U.S.C. chapters 11 and 79.
The COVID-19 Case Management System collects records of vaccinations, testing and contact tracing. Providing the
requested information is voluntary, however declining may result in being treated as not fully vaccinated for
purposes of implementing safety measures, including with respect to mask wearing, physical distancing, testing,
travel, and quarantine. This information is being collected and maintained to promote the safety of Federal buildings
and the Federal workforce consistent with the above-referenced authorities, the COVID-19 Workplace Safety: Agency
Model Safety Principles established by the Safer Federal Workforce Task Force, and guidance from the Centers for
Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA).
The information you provide will be included in a Privacy Act system of records and will be used and may be
disclosed for the purposes and routine uses described and published in the following System of Records Notices
(SORN): OPM/GOVT-10, Employee Medical File System of Records, 75 Fed. Reg. 35099 (June 21, 2010), amended 80
Fed. Reg. 74815 (Nov. 30, 2015); 09-25-0166 Radiation and Occupational Safety and Health Management
Information Systems, HHS/NIH/ORS.
If you have any questions or concerns, please contact the OMS Covid-19 Vaccination Program at
[email protected], or the Medical Director, NIH Occupational Medical Service, at 301-496-4411
or mail to: NIH Occupational Medical Service, Bldg 10, Rm 6C 310; 10 Center Drive, MSC 1584; Bethesda, MD 20892;
attn: Medical Director.
OMB# _______ EXPIRATION DATE: __/__/____
Public reporting burden for this collection of information is estimated to average 5 minute per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An Agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a current valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA 0975-0771. Do not return the completed form to this address.
Please click the box below to acknowledge the Privacy Act Notice and then click "Next Page" to continue.
By checking this box, I hereby acknowledge the Privacy Act Notice.

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Employee Information
Were you vaccinated only at NIH? (i.e., you received all doses, including any boosters, at NIH) If you select YES and
received all doses/boosters at NIH, then you DO NOT NEED TO SUBMIT THIS FORM.
Yes

No

First Name

Middle Name

Last Name

NIH ID Number (no dashes)

__________________________________

__________________________________

__________________________________

__________________________________
(Enter your NIH ID Number, including any zeros, and
without any dashes (e.g., 0012345678).)

Please make sure your NIH ID Number has all 10 digits and DOES NOT contain dashes.
Need help finding your NED ID Number?

Show Help

Ways to find your NIH ID Number:
The 10-digit Personal Identifier on the back of your PIV card (see image below). Look it up by searching your name
in the NIH Enterprise Directory (NED) at https://ned.nih.gov (must be connected to the NIH Network or VPN). If you
do not have access to the NIH Network, your Administrative Officer or Human Resources Specialist can look it up on
your behalf.

Email Address
(either NIH or personal email)

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__________________________________
(Enter your email so that you may be contacted if
there are questions on your submission.)

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Choose Your Form
Do you need to report your first dose(s)?
If you have previously completed this form to report your Primary Vaccination Series (Dose 1, Dose 2, etc.), then you
do not need to complete this part again unless you were notified otherwise.
YES - I need to report my initial vaccine dose(s)

NO - I have already reported my initial vaccine dose(s)

Note: You will have an opportunity to submit any additional doses or boosters after you enter your initial dose
information.
Please review your information. If you need to make changes, click the Previous Page button at the bottom of the
screen.
First Name: [first_name]
Middle Name: [middle_name]
Last Name: [last_name]
NED ID: [hhs_id]
Email Address: [email_address]

If this information is correct, click Next Page to continue to the next section.

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Vaccination Information
Were you vaccinated only at NIH? (i.e., you received BOTH of your first doses of Moderna or Pfizer, or received
Janssen (Johnson & Johnson) at NIH) If you select YES and received your initial vaccinations at NIH, then you DO NOT
NEED TO SUBMIT THIS FORM.
Yes

No

Persons are considered "fully vaccinated" two weeks after completing the full series of a COVID-19 vaccine approved
or authorized for emergency use by the U.S. Food and Drug Administration or that has been listed for emergency use
by the World Health Organization (e.g., Pfizer, Moderna, Janssen, AstraZeneca/Oxford, etc.), or a full vaccine series
(not a placebo) in a clinical trial (e.g., Novavax).
If you have received all the required doses but it has been less than two weeks since your last dose, select the "I am
fully vaccinated" option to complete this form.  However, you are still subject to the safety requirements of a person
not fully vaccinated until the two weeks have passed.
If you have received one dose of a two-dose vaccine, even if you are scheduled for your second dose, select "I am
not fully vaccinated."
If you are not vaccinated due to medical or religious reasons, select "I am not fully vaccinated."
For persons who choose not to complete the form, it will be assumed that they are not fully vaccinated for the
purposes of applicable safety measures and/or compliance with vaccination policy requirements. 
Please click the box that describes your current
COVID-19 vaccination status

I am fully vaccinated.
I am not fully vaccinated.

Have you received Dose 1 and are scheduled to receive
your Dose 2 at a later date?

Yes
No

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Additional Information
Are you partially vaccinated for COVID-19?

NO - I have not received any doses.
YES - I have received ONE DOSE of a two-dose
vaccine.

Vaccine Manufacturer

Moderna
Pfizer-BioNTech
Janssen (Johnson & Johnson)
Other

Vaccine Manufacturer

Moderna
Pfizer-BioNTech
Other

Other Manufacturer:

How many doses did you receive of this vaccine?

__________________________________
(Enter the vaccine manufacturer (e.g.,
AstraZeneca/Oxford, Novavax, etc.))
One
Two

Dose 1 Information
First Dose Date (you have not received a second dose)

__________________________________
(Please enter the date that you received your first
dose.)

Vaccination dates must be on or before today's date.
First Dose Date

__________________________________
(Please enter the date that you received your first
dose.)

Vaccination dates must be on or before today's date.

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Select the state where you received your Dose 1

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Alabama (AL)
Alaska (AK)
American Samoa (AS)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Federated States of Micronesia (FM)
Florida (FL)
Georgia (GA)
Guam (GU)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Marshall Islands (MH)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Northern Mariana Islands (MP)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Palau (PW)
Pennsylvania (PA)
Puerto Rico (PR)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virgin Islands (VI)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
Other - International

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Administration Site (select one)

Vaccine Lot Number (if known)

Mass Vaccination Site
Pharmacy
Primary Care Physician
Other

__________________________________

Dose 2 Information
Second Dose Date

__________________________________
(Please enter the date that you received your
second dose.)

Dose 2 date must be after Dose 1 date.
Dose 1 and 2 dates must be on or before today's date.
If you have not received Dose 2, please select the "I am not fully vaccinated" option on the previous page.

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Select the state where you received your Dose 2

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Alabama (AL)
Alaska (AK)
American Samoa (AS)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Federated States of Micronesia (FM)
Florida (FL)
Georgia (GA)
Guam (GU)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Marshall Islands (MH)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Northern Mariana Islands (MP)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Palau (PW)
Pennsylvania (PA)
Puerto Rico (PR)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virgin Islands (VI)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
Other - International

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Administration Site (select one)

Vaccine Lot Number (if known)

Mass Vaccination Site
Pharmacy
Primary Care Physician
Other

__________________________________

Upload Proof of Vaccination Acceptable forms of documentation include a copy of:
The record of immunization from a health care provider or pharmacy The COVID-19 Vaccination Record Card (CDC
Form MLS-319813_r, published on September 3, 2020) Medical records documenting the vaccination Immunization
records from a public health or state immunization information system ______  (required)

I need to upload a second file (optional)
Upload Proof of Vaccination (optional second file)

Select a reason for not receiving full vaccination
(whether partially vaccinated or not)

I request a medical exemption
I request a religious exemption

Please note that you will be contacted with further information.

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Verify Your Information
Please review your information and click Submit at the bottom of the page. If you need to make changes, click the
Previous Page button.
Please review your information. If you need to make changes, click the Previous Page button two times to return to
the entry form.
First Name: [first_name]
Middle Name: [middle_name]
Last Name: [last_name]
NED ID: [hhs_id]
Email Address: [email_address]
Click Submit to continue to the Booster and/or Dose 3 Form.
Verify Vaccination Information Vaccination Status:
Manufacturer: [vax_manufacturer]

[vax_status]

Verify Vaccination Information Vaccination Status:
Manufacturer: [partial_vax_manufacturer]

[vax_status]

Verify Vaccination Information Vaccination Status:
Manufacturer: [manufacturer_other]

[vax_status]

Verify Dose 1 Information Date (mm-dd-yyyy):
State Administered: [state1]
Site Administered: [admin_site_primary1]
Lot Number: [lot_num1]

[date_first_dose]

Verify Dose 1 Information Date (mm-dd-yyyy):
State Administered: [state1]
Site Administered: [admin_site_primary1]
Lot Number: [lot_num1]

[partial_date_first_dose]

Verify Dose 2 Information Date (mm-dd-yyyy):
State Administered: [state2]
Site Administered: [admin_site_primary2]
Lot Number: [lot_num2]

[date_second_dose]

Proof of Vaccination File: [vax_card1:label] [vax_card1:inline]
Second Proof of Vaccination File: [vax_card1:label] [vax_card2:inline]
Reason not fully vaccinated:

[not_vax].

Do you need to report a Booster and/or extra dose due to a medical condition (Dose 3)?
Yes

No

If your information above is complete and accurate to the best of your knowledge, click Submit. Notice: By clicking
Submit, I understand that a knowing and willful false statement on this form may be punishable by fine and/or
imprisonment (18 U.S.C. 1001) and could result in additional administrative action, including an adverse personnel
action, up to and including removal from my position.

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Booster and Dose 3 Form

COVID-19 Booster and Additional Dose Information
Did you receive your COVID-19 Booster Dose at NIH?  If you select YES and received your booster at NIH, then you
DO NOT NEED TO SUBMIT THIS FORM.  The form will end and your response will not be saved.
Yes

No

Select the vaccination type you would like to report
first. You may enter additional doses on the next
page.

Booster Dose
Dose 3 (immunocompromised)

[vax_type_1] Information
Manufacturer

Other Manufacturer:

Lot Number (if known)

Date of Vaccination

Moderna
Pfizer-BioNTech
Janssen (Johnson & Johnson)
Other

__________________________________
(Enter the vaccine manufacturer (e.g.,
AstraZeneca/Oxford, Novavax, etc.))

__________________________________

__________________________________
(Please enter the date that you received your third
dose.)

Vaccination date must be on or before today's date!

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State where you received your vaccination

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Alabama (AL)
Alaska (AK)
American Samoa (AS)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Federated States of Micronesia (FM)
Florida (FL)
Georgia (GA)
Guam (GU)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Marshall Islands (MH)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Northern Mariana Islands (MP)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Palau (PW)
Pennsylvania (PA)
Puerto Rico (PR)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virgin Islands (VI)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
Other - International

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Administration Site (select one)

Mass Vaccination Site
Pharmacy
Primary Care Physician
Other

Upload Proof of Vaccination ______ (required) Click Upload file above and choose a file format such as a PDF or an
image format such as a JPEG, PNG, or TIFF file. Please note, HEIC file format is NOT accepted.
Acceptable forms of documentation include a copy of:
The record of immunization from a health care provider or pharmacy The COVID-19 Vaccination Record Card (CDC
Form MLS-319813_r, published on September 3, 2020) Medical records documenting the vaccination Immunization
records from a public health or state immunization information system
Would you like to enter another booster or additional
dose?

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Yes, I need to add more
No, I'm done

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COVID-19 Booster and Additional Dose Information
Select the next vaccination type you would like to
report. You may enter additional doses on the next
page.

Booster Dose
Dose 3 (immunocompromised)

[vax_type_2] Information
Manufacturer

Other Manufacturer:

Lot Number (if known)

Date of Vaccination

Moderna
Pfizer-BioNTech
Janssen (Johnson & Johnson)
Other

__________________________________
(Enter the vaccine manufacturer (e.g.,
AstraZeneca/Oxford, Novavax, etc.))

__________________________________

__________________________________
(Please enter the date that you received your third
dose.)

Vaccination date must be on or before today's date!

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State where you received your vaccination

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Alabama (AL)
Alaska (AK)
American Samoa (AS)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Federated States of Micronesia (FM)
Florida (FL)
Georgia (GA)
Guam (GU)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Marshall Islands (MH)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Northern Mariana Islands (MP)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Palau (PW)
Pennsylvania (PA)
Puerto Rico (PR)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virgin Islands (VI)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
Other - International

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Administration Site (select one)

Mass Vaccination Site
Pharmacy
Primary Care Physician
Other

Use the file uploaded on the previous page?

Use the file I already uploaded
I need to upload a different file

Use this file: [vax_card_1:label]
[vax_card_1:inline]
Upload Proof of Vaccination ______ (required) Click Upload file above and choose a file format such as a PDF or an
image format such as a JPEG, PNG, or TIFF file. Please note, HEIC file format is NOT accepted.
Acceptable forms of documentation include a copy of:
The record of immunization from a health care provider or pharmacy The COVID-19 Vaccination Record Card (CDC
Form MLS-319813_r, published on September 3, 2020) Medical records documenting the vaccination Immunization
records from a public health or state immunization information system
Would you like to enter another booster or additional
dose?

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Yes, I need to add more
No, I'm done

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Verify Your information
Please review your information and click Submit at the bottom of the page.  If you need to make changes, click the
Previous Page button.
First Name: [first_name]
Middle Name: [middle_name]
Last Name: [last_name]
NED ID: [hhs_id]
Email Address: [email_address]
Verify [vax_type_1] Information Manufacturer:  [manufacturer_1]
Other (if selected):  [manufacturer_other_1]
Date (mm-dd-yyyy):  [dose_date_1]
State Administered:  [state_1]
Site Administered:  [admin_site_1]
Lot Number:  [lot_num_1]
Proof of Vaccination:  [vax_card_1:inline]
Verify [vax_type_2] Information Manufacturer:  [manufacturer_2]
Other (if selected):  [manufacturer_other_2]
Date (mm-dd-yyyy):  [dose_date_2]
State Administered:  [state_2]
Site Administered:  [admin_site_2]
Lot Number:  [lot_num_2]
Proof of Vaccination:  [vax_card_2:inline]
If your information above is complete and accurate to the best of your knowledge, click Submit. Notice: By clicking
Submit, I understand that a knowing and willful false statement on this form may be punishable by fine and/or
imprisonment (18 U.S.C. 1001) and could result in additional administrative action, including an adverse personnel
action, up to and including removal from my position.

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