COVID-19 Vaccination Status Form

This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. § 552a): The information requested in the COVID-19 Case Management System is authorized to be collected pursuant to NIH Policy Manual 0004 NIH COVID-19 Vaccination Policy for Healthcare Workforce, Department of Health and Human Services (HHS) memo (Aug. 6, 2021), Policy to Require COVID-19 Vaccinations for Certain HHS Employees and Other Staff, section 402 of the Public Health Service Act, the Office of Personnel Management (OPM) regulation 5 C.F.R. § 339.205, Executive Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), Executive Order 12196, Occupational Safety and Health Program for Federal Employees (Feb. 26, 1980), and 5 U.S.C. chapters 11 and 79.

The COVID-19 Case Management System collects records of vaccinations, testing and contact tracing. Providing the requested information is voluntary, however declining may result in being treated as not fully vaccinated for purposes of implementing safety measures, including with respect to mask wearing, physical distancing, testing, travel, and quarantine. This information is being collected and maintained to promote the safety of Federal buildings and the Federal workforce consistent with the above-referenced authorities, the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force, and guidance from the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA).

The information you provide will be included in a Privacy Act system of records and will be used and may be disclosed for the purposes and routine uses described and published in the following System of Records Notices (SORN): OPM/GOVT-10, Employee Medical File System of Records, 75 Fed. Reg. 35099 (June 21, 2010), amended 80 Fed. Reg. 74815 (Nov. 30, 2015); 09-25-0166 Radiation and Occupational Safety and Health Management Information Systems, HHS/NIH/ORS.

If you have any questions or concerns, please contact the OMS Covid-19 Vaccination Program at OMSCovidVaccineProgram@mail.nih.gov, or the Medical Director, NIH Occupational Medical Service, at 301-496-4411 or mail to: NIH Occupational Medical Service, Bldg 10, Rm 6C 310; 10 Center Drive, MSC 1584; Bethesda, MD 20892; attn: Medical Director.

OMB# 0925-0771

EXPIRATION DATE: 04/30/2025

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 0975-0771. Do not return the completed form to this address.

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COVID-19 Vaccination Status Form

Privacy Act Statement

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