COVID-19 Vaccination Attestation Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0613 can be found here:

Documents and Forms

Document Name Document Type
Form DD 3150 COVID-19 Vaccination Attestation Form Form and Instruction
DD 3150 Certification of Vaccination DD3150_Certificate of Vaccination_ 20210824_DRAFT.pdf Form and Instruction
DD 3150 Certification of Vaccination DD3150_Certificate of Vaccination_ 20210824_DRAFT.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	COVID-19 Vaccination Attestation Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DD 3150	Certification of Vaccination	DD3150_Certificate of Vaccination_ 20210824_DRAFT.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,500,000	3,500,000
Annual IC Time Burden (Hours)	116,667	116,667
Annual IC Cost Burden (Dollars)	3,150,000	3,150,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

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