COVID-19 Vaccine Survey

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Document Name Document Type
Form 2900-0876-AA2-1 COVID-19 Vaccine Survey Form and Instruction
2900-0876-AA2-1 COVID-19 Vaccine Trial VA interaction COVID-19 VACCINE TRIAL_EMD 1_V5.A_102920.pdf Form and Instruction
2900-0876-AA2-2 COVID-19 Vaccine Trial Appointment COVID-19 VACCINE TRIAL_EMD 2_V5.A_102920.pdf Form and Instruction
2900-0876-AA2-3 COVID-19 Vaccine Trial Study Team COVID-19 VACCINE TRIAL_V5.A_StudyTeam_110320.pdf Form and Instruction
2900-0876-AA2-4 COVID-19 Vaccine Trial VA.Gov COVID-19 VACCINE TRIAL_VA.GOV_V5.A_102920.pdf Form and Instruction
A-11 Fast-Track Clearance Request Template_COVID Vaccine.pdf A-11 Fast-Track Clearance Request Template_COVID Vaccine IC Document
COVID Vaccine Survey Sampling Plan.pdf COVID Vaccine Survey Sampling Plan IC Document

Information Collection (IC) Details

IC Title:	COVID-19 Vaccine Survey	Agency IC Tracking Number:	2900-0876-AA2

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2900-0876-AA2-1	COVID-19 Vaccine Trial VA interaction	COVID-19 VACCINE TRIAL_EMD 1_V5.A_102920.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AA2-2	COVID-19 Vaccine Trial Appointment	COVID-19 VACCINE TRIAL_EMD 2_V5.A_102920.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AA2-3	COVID-19 Vaccine Trial Study Team	COVID-19 VACCINE TRIAL_V5.A_StudyTeam_110320.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876-AA2-4	COVID-19 Vaccine Trial VA.Gov	COVID-19 VACCINE TRIAL_VA.GOV_V5.A_102920.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,000	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	15,000	15,000
Annual IC Time Burden (Hours)	1,250	1,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
A-11 Fast-Track Clearance Request Template_COVID Vaccine	A-11 Fast-Track Clearance Request Template_COVID Vaccine.pdf	11/03/2020
COVID Vaccine Survey Sampling Plan	COVID Vaccine Survey Sampling Plan.pdf	11/03/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.