Information Collection

COVID-19 Attestation Form

IC 241849 under ICR 202005-1218-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 COVID-19 Attestation Form	Form
1 COVID-19 Attestation Form 1218-0NEW Covid Attestation Form FINAL 5.15 1716.docx	Form
1218-0NEW Draft USDAOSHA Attestation Letter 5.10.docx COVID-19 Attestation Form Instructions	IC Document

IC Title:

Agency IC Tracking Number:

1218-0NEW COVID-19 .1

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	COVID-19 Attestation Form	1218-0NEW Covid Attestation Form FINAL 5.15 1716.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,819

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11,276	11,276
Annual IC Time Burden (Hours)	4,886	4,886
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
COVID-19 Attestation Form Instructions	1218-0NEW Draft USDAOSHA Attestation Letter 5.10.docx	05/17/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.