Report a COVID-19 Vaccination Received in the Community (non-NIH vaccination facility)

Background: The National Institutes of Health (NIH) has received a limited number of COVID-19 vaccines for NIH staff. Prioritization of vaccine distribution to NIH staff is based on likely risk of workplace exposure to SARS-CoV-2 (the virus that causes COVID-19) and risk of transmission of SARS-CoV-2 to/from others in the workplace. The NIH vaccine distribution plan prioritization is generally consistent with CDC guidance. Vaccination is also possible in the community, and community availability is increasing. If NIH is notified when staff are vaccinated in the community, NIH may adjust prioritization lists to ensure invitations are sent as quickly as possible to eligible staff who have not yet received a COVID-19 vaccine. 

Purpose: This form is voluntary and only for staff of the National Institutes of Health (NIH). The purpose of this form is to report a COVID-19 vaccination that you have received in your community (i.e., from a provider other than NIH). Please only submit this form once, even if your vaccine manufacturer requires two doses. There is no need to provide any further documentation of your vaccination other than this form.

Privacy Act Statement

This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. § 552a): The information requested on this form is authorized to be collected pursuant to 5 U.S.C. 1302, 2951, 4118, 4308, 4506, 7501, 7511, 7521 and Executive Order 10561. In addition, collection is authorized under Executive Order 12196; Public Health Emergency. Completing the form is voluntary, however declining to provide any or all the requested information may result in failure to target vaccine supplies appropriately for the protection of critical NIH assets, including vulnerable patients and essential NIH workers. The principal purpose for which the information will be used is to adjust vaccine prioritization administered by the Occupational Medical Services (OMS), Division of Occupational Health and Safety (DOHS), Office of Research Services (ORS), National Institutes of Health (NIH), U.S. Department of Health and Human Services (HHS) based on self-reported vaccination status.

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 Notice (SORN):  09-25-0105 Administration: Health Records of Employees, Visiting Scientists, Fellows, and Others Who Receive Medical Care Through the Employee Health Unit. https://www.federalregister.gov/documents/2002/09/26/02-23965/privacy-act-of-1974-annual-publication-of-systems-of-records