COVID-19 Vaccine Screening and Immunization Documentation

OMB 0720-0068

The Defense Health Agency (DHA) has created the DHA Form 207, “COVID-19 Vaccine Screening and Immunization Documentation” to determine if the COVID-19 vaccine can be administered to a patient. The DHA Form 207 will be used to determine and document patient eligibility and vaccine declinations for a COVID-19 vaccination. Respondents include Active Duty military members, Federal employees, beneficiaries, and contractors (based on their employment) who wish to receive the vaccine.

The latest form for COVID-19 Vaccine Screening and Immunization Documentation expires 2021-07-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 236 Pediatric (5-11 years) COVID-19 Vaccine Screening and Immunization Documentation Form and Instruction
Form 207 COVID-19 Vaccine Screening and Immunization Documentation Form and Instruction
0720-0068_Justification for Change_11.18.2021.docx Justification for No Material/Nonsubstantive Change
0720-0068_Ref 2_Pfizer 5 though 11 Fact Sheet for Recipients-COVID-19 Vaccine Final.pdf Supplementary Document
0720-0068_SSA_11.17.2021v3.docx Supporting Statement A
Reply to HHS comments Covid-19 Screening Docummentation Form 12 Jan.docx Supplementary Document
IHD Response to CDC comments.pdf Supplementary Document
Pfizer-BioNTECH COVID-19 Vaccine EUA Fact sheet for Recipients revised 12-23-20.pdf Supplementary Document
0397469 Coronavirus Disease 2019 Vaccine Guidance (OSD011566-20) eligibility.pdf Supplementary Document
Pediatric (5-11 years) COVID-19 Vaccine Screening and Immunization Documentation Form and Instruction
COVID-19 Vaccine Screening and Immunization Documentation Form and Instruction

All Historical Document Collections

202111-0720-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2021-11-18
202106-0720-004 Approved with change	Revision of a currently approved collection	2021-06-30
202101-0720-001 Approved without change	New collection (Request for a new OMB Control Number)	2021-01-13