COVID-19 Vaccination Attestation Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD 3150 COVID-19 Vaccination Attestation Form	Form and Instruction	New	Missing upstream
Supporting Statement Part A_4.23.2021 - Vaccination Attestation Form v9_20210824.docx	Supporting Statement A	Uploaded 2021-08-24	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
248989	COVID-19 Vaccination Attestation Form	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202108-0704-008
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOD/DODDEP	Agency Tracking No:
Title: COVID-19 Vaccination Attestation Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 08/25/2021
Date Submitted to OIRA: 08/24/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	3,500,000	0
Time Burden (Hours)	116,667	0
Cost Burden (Dollars)	3,150,000	0

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Abstract: This information is being requested in order to promote the safety of individuals in Federal buildings and on DoD installations, consistent with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force and guidance from the CDC and the Occupational Safety and Health Administration. This information will be used by DoD staff charged with implementing and enforcing workplace safety protocols and is required for ensuring compliance with the requirement for attestation by all civilian employees, on-site contractors, and official visitors. Vaccination status for Military Service members will be obtained by alternate means using DoD’s Individual Medical Readiness system.

Emergency Justfication: Consistent with guidance from the Centers for Disease Control and Prevention (CDC), and guidance from the Safer Federal Workforce Task Force established pursuant to Executive Order 13991, “Protecting the Federal Workforce and Requiring Mask-Wearing” (January 20, 2021), the Department of Defense (DoD) is establishing specific safety protocols concerning individuals fully vaccinated and not fully vaccinated against coronavirus disease 2019 (COVID-19). Individuals who attest that they are not fully vaccinated against COVID-19 or who choose not to provide this information will be required to comply with applicable CDC and DoD guidance for individuals not fully vaccinated against COVID-19, including wearing masks regardless of the transmission rate in a given area, physical distancing, regular screening testing, and adhering to applicable travel requirements

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Authorizing Statute(s): None

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

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
COVID-19 Vaccination Attestation Form	DD 3150	Certification of Vaccination

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ICR Summary of Burden

table that charts list 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	3,500,000	0	0	3,500,000	0	0
Annual Time Burden (Hours)	116,667	0	0	116,667	0	0
Annual Cost Burden (Dollars)	3,150,000	0	0	3,150,000	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: New collection with a new associated burden

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Annual Cost to Federal Government: $98,900,000

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? No

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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: 08/24/2021

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