SUPPORTING STATEMENT - PART A
COVID-19 Vaccine Screening and Immunization Documentation DHA Form 207 – OMB Control Number 0720-XXXX
1. Need for the Information Collection
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. This collection of information is authorized by Public Law 104-191, 10 U.S.C., Chapter Ch. 55, Medical and Dental Care; DHA-IPM 20-004, “DoD Coronavirus Disease (COVID-19) Vaccination Program Implementation." The IPM is the implementation guide for all Military Treatment Facilities (MTF).
2. Use of the Information
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. Respondents are given paper copies of the form at an immunization clinic (on base or their local MTF). Respondents will complete Part I of the form and return it to a technician prior to receiving the vaccine. Part II and Part III of the form are completed by the screener and the vaccinator, respectively. No invitations or communications are sent to respondents. After vaccination the technician then enters the information on the form into the Electronic Medical Record (EMR)/IMR to document the vaccination.
3. Use of Information Technology
0% of responses are collected electronically. Respondents provided their responses by filling out a paper form, the information from the form is then entered by a technician into the EMR. Electronic submissions may occur in the future as DHA evaluates the efficacy of the screening and immunization process.
4. Non-duplication
The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.
5. Burden on Small Businesses
This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.
6. Less Frequent Collection
The information collected through the DHA Form 207 is provided on the occasion that a patient, specifically beneficiaries or contractors, decide they want to receive or decline the COVID-19 vaccination.
7. Paperwork Reduction Act Guidelines
This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
Part A: PUBLIC NOTICE
This collection request is being submitted as an emergency submission. A 60-Day and 30-Day Federal Register Notice will be published when DHA seeks regular approval for this collection.
Part B: CONSULTATION
Comments were received from the Office of Management and Budget (Office of the General Counsel), Food and Drug Administration, Center for Disease Control, and the Department of Health and Human Services. The Defense Health Agency (Immunization Healthcare Division) response to those comments have been provided as a part of this emergency submission.
9. Gifts or Payment
No payments or gifts are being offered to respondents as an incentive to participate in the collection.
10. Confidentiality
A Privacy Act Statement is provided at the top of the form.
A System of Record Notice (SORN) is required for this collection. EDHA 07, Military Health Information System is available at https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/DHA/
EDHA-07.pdf.
A Privacy Impact Assessment (PIA) is not required for this collection because PII is not being collected electronically.
Records Retention and Disposition Schedule: Temporary. Cut off upon last episode of patient care or last entry to the patient record is annotated. Delete/Destroy when 75 years old.
11. Sensitive Questions
No questions considered sensitive are being asked in this collection.
12. Respondent Burden and its Labor Costs
Part A: ESTIMATION OF RESPONDENT BURDEN
DHA Form 207
Number of Respondents: 9,000,000
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 9,000,000
Response Time: 10 minutes
Respondent Burden Hours: 1,500,000 hours
Total Submission Burden
Total Number of Respondents: 9,000,000
Total Number of Annual Responses: 9,000,000
Total Respondent Burden Hours: 1,500,000 hours
Part B: LABOR COST OF RESPONDENT BURDEN
DHA Form 207
Number of Total Annual Responses: 9,000,000
Response Time: 10 minutes
Respondent Hourly Wage: $7.25
Labor Burden per Response: $1.21
Total Labor Burden: $10,875,000.00
Overall Labor Burden
Total Number of Annual Responses: 9,000,000
Total Labor Burden: $10,875,000.00
Federal minimum wage was used to estimate labor burden as the hourly wages between beneficiaries and contractors vary extremely.
13. Respondent Costs Other than Burden Hour Costs
There are no annualized costs to respondents other than the labor burden costs addressed in Section 12 of this document to complete this collection.
14. Cost to the Federal Government
Part A: LABOR COST TO THE FEDERAL GOVERNMENT
DHA Form 207
Number of Total Annual Responses: 9,000,000
Processing Time per Response: .25 hours
Hourly Wage of Worker(s) Processing Responses : $32.29
Cost to Process Each Response: $8.07
Total Cost to Process Responses: $72,652,500.00
Overall Labor Burden to the Federal Government
Total Number of Annual Responses: 9,000,000
Total Labor Burden: $72,652,500.00
Part B: OPERATIONAL AND MAINTENANCE COSTS
Cost Categories
Equipment: $0.00
Printing: $ 450,000.00
Postage: $0.00
Software Purchases: $0.00
Licensing Costs: $0.00
Other: $0.00
Total Operational and Maintenance Cost: $450,000.00
Part C: TOTAL COST TO THE FEDERAL GOVERNMENT
Total Labor Cost to the Federal Government: $72,652,500.00
Total Operational and Maintenance Costs: $450,000.00
Total Cost to the Federal Government: $73,102,500.00
15. Reasons for Change in Burden
This is a new collection with a new associated burden.
16. Publication of Results
The results of this information collection will not be published.
17. Non-Display of OMB Expiration Date
We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.
18. Exceptions to “Certification for Paperwork Reduction Submissions”
We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kaitlin Chiarelli |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |