Information Collection

COVID-19 Vaccination Attestation Form

IC 248989 under ICR 202108-0704-008 · OMB 0704-0613.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.