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NIH COVID-19 Vaccination Status Form
NIH COVID-19 Vaccination Status Form
OMB: 0925-0771
IC ID: 249128
OMB.report
HHS/NIH
OMB 0925-0771
ICR 202110-0925-001
IC 249128
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0771 can be found here:
2022-06-23 - No material or nonsubstantive change to a currently approved collection
2022-03-16 - Revision of a currently approved collection
Documents and Forms
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
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
NIH COVID-19 Vaccination Status Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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 and Instruction
1
NIHCOVID-19 Vaccination Status Form
NIH COVID-19 Vaccination Status Form_Example-Fully-Vaccinated (2).pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
31,000
0
0
0
0
31,000
Annual IC Time Burden (Hours)
2,583
0
0
0
0
2,583
Annual IC Cost Burden (Dollars)
0
0
0
0
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.