Form 1 NIHCOVID-19 Vaccination Status Form

COVID-19 Vaccination Status Form

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Privacy Act Statement
Overview:
We value the trust and confidence that you place in the NIH Occupational Medical Service (OMS), and we are
committed to protecting your privacy. The Personally Identifiable Information (PII) about you collected in this
form will be stored in your OMS Electronic Health Record (EHR). The OMS EHR is a government application.
The OMS EHR application is hosted on internal servers operated by the Office of Research Services (ORS),
Office of Innovation and Information Technology (OIIT) and by the National Institutes of Health Clinical
Center's (NIH/CC) Department of Clinical Research Informatics (DCRI). The Federal Government has
implemented a COVID-19 vaccination requirement for all federal employees and contractors. This is a result
of two Executive Orders, in combination with implementation guidelines issued by the Safer Federal
Workforce Task Force in President Biden's Executive Order 13991. The information collected in this notice will
be used to ensure compliance with these requirements.
Authority:
Pursuant to the Executive Order on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees,
the Executive Order on Ensuring Adequate COVID Safety Protocols for Federal Contractors requires all
persons to receive the COVID-19 vaccination, and 5 C.F.R. § 339.205 under which OPM authorizes agencies to
establish immunization programs for employees who are exposed to significant health or safety risks by
nature of their work. The legal authority to operate and maintain this Privacy Act System of Records is 42
U.S.C. 241 and 5 U.S.C. 7902.
Purpose:
This information is being collected and maintained to promote the safety of the Federal workplace 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). 
Routine Uses:
While the information requested on this form is intended to be used primarily for internal purposes, in
certain circumstances it may be necessary to disclose this information externally, for example to disclose
information to: a Federal, State, or local agency to the extent necessary to comply with laws governing
reporting of immunizations or safety in the work environment; to contractors or volunteers as necessary to
perform their duties for the Federal Government; to other agencies, courts, and persons as necessary and
relevant in the course of litigation, and as necessary and in accordance with requirements for law
enforcement; or to a person authorized to act on your behalf. A complete list of the routine uses can be
found in the system of records notice associated with this collection of information 09-25-0166, Radiation
and Occupational Safety and Health Management Information Systems, HHS/NIH/ORS, 09-40-0002, Public
Health Service (PHS) Commissioned Corps Commissioned Corps Medical Records, HHS/PSC/HRS, and
OPM/GOVT-10, Employee Medical File System Records. 
Consequences for Not Providing Information:
Providing this information is required as outlined in the Executive Orders and the information provided by
the Safer Federal Workforce Taskforce. If you fail to provide this information, you will be treated as not fully
vaccinated. Additionally, failure to complete this form, or provide vaccination information, may result in
disciplinary action.
Point of Contact Information:
If you have any questions or concerns, please contact the OMS Covid-19 Vaccination Program at
OMSCovidVaccineProgram@mail.nih.gov, or the Medical Director, NIH Occupational Medical Service, at 301496-4411 or mail to: NIH Occupational Medical Service, Bldg 10, Rm 6C 310; 10 Center Drive, MSC 1584;
Bethesda, MD 20892; attn: Medical Director.
OMB# 0925-0925-0771

EXPIRATION DATE: 03/31/2022

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.
* must provide value

By checking this box, I hereby accept the Privacy Act Notice.

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COVID-19 Vaccination Status Form

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Employee Information
Introduction
The Office of Research Services, Division of Occupational Health and Safety, Occupational Medical Service
already has the information for those vaccinated within the NIH COVID-19 Vaccine Program. Those
vaccinated within the NIH vaccination program are not being asked to complete this form at this time.
This form is for those who have declined to be vaccinated or who are fully or partially vaccinated through
publicly available means (e.g., in the community at mass vaccination sites, pharmacies, healthcare facilities).
Providing 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 your position.

Were you vaccinated only at NIH?   (i.e., you received BOTH doses of
Moderna or Pfizer, or received Janssen (Johnson & Johnson) at NIH)
If you select YES and received your full series of vaccinations at NIH, then you DO NOT NEED TO
SUBMIT THIS FORM.
* must provide value

Yes
No
reset

First Name

Test

* must provide value

Middle Name

Middle Name

Last Name

Test

* must provide value

NIH ID Number (no dashes)
* must provide value

Need help finding your NED ID Number?

0000000000
0 characters remaining

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

Show Help

Your NIH ID Number is the 10-digit Personal Identifier on the back of your PIV card.  You can also look
it up by searching your name in the NIH Enterprise Directory at https://ned.nih.gov (must be
connected to the NIH Network or VPN).

Email Address
* must provide value

test@test.com
Please enter your email address so that you may be
contacted if there are questions on your submission.

Please note that at the bottom of any page in this form, you can click "Save & Return Later" to get a
personalized survey link and a Return Code.

Important:  To use this option, you will need both the survey link and your return code. Be sure to
copy down your Return Code from the Save & Return page -- it will NOT be emailed to you with the
link.

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COVID-19 Vaccination Status Form

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Vaccination Information
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
* must provide value

I am fully vaccinated.
I am not fully vaccinated.
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COVID-19 Vaccination Status Form

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Additional Information
Vaccine Manufacturer

Moderna

* must provide value

Pfizer-BioNTech
Janssen (Johnson & Johnson)
Other
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Dose 1 Information
First Dose Date

09-01-2021

M-D-Y

* must provide value

Please enter the date that you received your first dose.

Health care professional or clinic site who
administered your Dose 1

e.g., CVS, Six Flags

CVS

* must provide value

Select the state where you received your Dose 1

Maryland (MD)

* must provide value

Vaccine Lot Number (if known)

ABCD123

Dose 2 Information
Second Dose Date
* must provide value

Health care professional or clinic site who
administered your Dose 2

09-22-2021

M-D-Y

Please enter the date that you received your second
dose.

CVS
e.g., CVS, Six Flags

* must provide value

Select the state where you received your Dose 2

Maryland (MD)

* must provide value

Vaccine Lot Number (if known)

ABCD123

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
Test_UploadFile.xlsx (0.01 MB)
 Upload new version or  Remove file

  (required)

I need to upload a second file (optional)

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COVID-19 Vaccination Status Form

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If you are finished and ready to submit your information, 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.
If you are not ready to submit your form, you can click "Save & Return Later" to send a unique return link to
your email. Important: To use this option, you must copy down your Return Code from the Save &
Return page since it will NOT be emailed to you with the link.

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