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Screening Questionnaire
NIH COVID-19 Vaccination Status Form
OMB: 0925-0771
IC ID: 252169
OMB.report
HHS/NIH
OMB 0925-0771
ICR 202206-0925-002
IC 252169
( )
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
View Information Collection (IC)
IC Title:
Screening Questionnaire
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
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
Federal Enterprise Architecture Business Reference Module
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 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
35,500
0
0
0
0
35,500
Annual IC Time Burden (Hours)
2,958
0
0
0
0
2,958
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.