NIH COVID-19 Vaccination Status Form

Forms and Documents

Document Name	Status
Form 3 Building Access Form Form and Instruction	Unchanged
Form 2 Screening Questionnaire Form	Unchanged
Form 1 NIH COVID-19 Vaccination Status Form Form and Instruction	Modified
1b COVID19VaccinationStatusForm_2022-06-16.pdf Supplementary Document	2022-06-23
1a COVID19VaccinationStatusForm_2022-06-16 - Markup of Changes.pdf Supplementary Document	2022-06-23
Change Request Memo 0925-0771.docx Justification for No Material/Nonsubstantive Change	2022-06-23
pub 30day FRN2022-05475.pdf Supplementary Document	2022-03-15
Attachment 3PiaFrm_Privacy Module NSAT Annual Review Submited AA_2021.rtf Supplementary Document	2022-03-14
Attachment 2 PIA - NIDDK On-Site Web and Apps 8-4-2021.pdf Supplementary Document	2022-03-14
Support_Statement A_NIHCOVIDVacStatusForm.docx Supporting Statement A	2022-03-14

IC Document Collections

IC ID	Document Title	Status
252170	Building Access Form Form and Instruction	Unchanged
252169	Screening Questionnaire Form	Unchanged
249128	NIH COVID-19 Vaccination Status Form Form and Instruction	Modified

ICR Details

OMB Control No: 0925-0771	ICR Reference No: 202206-0925-002
Status: Received in OIRA	Previous ICR Reference No: 202203-0925-002
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: NIH COVID-19 Vaccination Status Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/23/2022

	Requested	Previously Approved
Expiration Date	04/30/2025	04/30/2025
Responses	102,000	102,000
Time Burden (Hours)	8,499	8,499
Cost Burden (Dollars)	0	0

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Abstract: The NIH now has a mandatory vaccination requirement that affects several thousand staff. We have been providing contractors, tenants, fellows, and other staff access to testing and vaccines during this pandemic. The information to be collected is needed to ensure we have the vaccination details for our staff (e.g., those providing essential services to the NIH via use agreements, visiting scientists, fellows and contractors, food service providers, and our three separate childcare providers) to comply with Executive Order 14042, Executive Order 14043, and U.S. Department of Health and Human Services (HHS) policy to mandate COVID-19 vaccinations for patient-facing health care staff. This revision request includes two new forms as NIH is implementing a building entry protocol where all people, federal government employees, contractors, patients, and visitors, will walk up to a door and scan a QR code with their phone and answer questions about Covid exposure every day.

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Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Safer Federal Workforce Task Force
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 66319	11/22/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 14544	03/15/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Building Access Form	3	Building Access Form
NIH COVID-19 Vaccination Status Form	1, 1	NIHCOVID-19 Vaccination Status Form ,   NIH COVID-19 Vaccination Status Form
Screening Questionnaire	2	screening questionnaire

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	102,000	102,000	0	0	0	0
Annual Time Burden (Hours)	8,499	8,499	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $117,135

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/23/2022

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