Certification of Vaccination

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DOE F 231.2 Certification of Vaccination	Form and Instruction	New	Repair queued
Supporting Statement A_ Certification of Vaccination.docx	Supporting Statement A	Uploaded 2021-08-17	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
248930	Certification of Vaccination	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202108-1910-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOE/DOEOA	Agency Tracking No:
Title: Certification of Vaccination
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: 08/19/2021
Date Submitted to OIRA: 08/17/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	15,000	0
Time Burden (Hours)	2,505	0
Cost Burden (Dollars)	145,766	0

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Abstract: This information collection is being established in order to promote the safety of Federal buildings, the Federal workforce, and others on site at agency facilities consistent with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force and guidance from the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration. Specifically, this information will be used by DOE staff charged with implementing and enforcing workplace safety protocols.

Emergency Justfication: Pursuant to the Office of Management and Budget (OMB) procedures established in 5 C.F.R Part 1320, Controlling Paperwork Burdens on the Public, the Department of Energy (DOE) is requesting that the proposed information of collection, Certification of Vaccination, be processed as an Emergency Clearance Information Collection Request (ICR) as referenced in 5 C.F.R. § 1320.13, Emergency processing. DOE has determined that the information is needed prior to the time periods established under Part 1320 of the regulation, and that this information is essential to DOE’s implementation of safety protocols as provided in recent guidance released by the Centers for Disease and Prevention (CDC) in Executive Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021). DOE must collect this information urgently due to the unanticipated COVID-19 pandemic. DOE determined that public harm is likely if normal clearance procedures are followed. Exposure to and transmission of COVID-19 will possibly be reduced by requesting the vaccination status of support service contractor employees entering DOE facilities. DOE is therefore requesting an Emergency Clearance to collect vaccination status information for a six-month approval period, allowing support service contractor employees who pre-COVID-19 were embedded with DOE staff in a Federal government owned or leased facility to attest to their vaccination status. During this approval period, DOE will work to establish a regular submission of this ICR.

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Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
  

Citations for New Statutory Requirements: EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing

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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
Certification of Vaccination	DOE F 231.2	Certification of Vaccination Form

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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	15,000	0	15,000	0	0	0
Annual Time Burden (Hours)	2,505	0	2,505	0	0	0
Annual Cost Burden (Dollars)	145,766	0	145,766	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $174,165

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? Yes

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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: 08/17/2021

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