Form 1 NIHCOVID-19 Vaccine Attestation instrument

OMB Control # XXXX-XXXX

Expiration Date XX/XX/202X

Public reporting burden for this collection of information is estimated to average .5 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to NIH, Project clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (XXXX-XXXX). Do not return the completed form to this address.

NIH COVID-19 Vaccination Attestation Intake Form
(non-NIH vaccination facility)

DEMOGRAPHIC BREAKDOWN: None

QUOTAS AND ELIGIBILITY: None

Introduction

August 2021

Introduction

We value the trust and confidence that you place in the NIH Occupational Medical Service (OMS), and we are committed to protecting your privacy. The Personally Identifiable Information (PII) about you collected in this form will be stored in your OMS Electronic Health Record (EHR). The OMS EHR is a government application. The OMS EHR application is hosted on internal servers operated by the Office of Research Services (ORS), Office of Innovation and Information Technology (OIIT) and by the National Institutes of Health Clinical Center’s (NIH/CC) Department of Clinical Research Informatics (DCRI). The NIH has a COVID-19 vaccination requirement for persons working in Building 10, those with patient contact, or probable patient contact. This policy, in combination with the guidelines issued by the Safer Federal Workforce Task Force created by President Biden’s Executive Order 13991 has instructed Federal Agencies to inquire about the COVID-19 vaccination status of persons (paid and unpaid) working onsite in Federal buildings. Additionally, the NIH now requires all persons working with patients or potentially having contact with patients to be vaccinated. The information collected in this notice will be used to ensure compliance with these requirements, generate the list of persons required to be tested weekly, and will provide important information regarding safety frameworks, guidance, and procedures.

Eligibility Questions (See following pages)

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