Certification of Vaccine Form (NIGC)

Forms and Documents

Document	Type	Status	Availability
Form 3206-0277 Certification of Vaccination Common Form	Form	New	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
248966	Certification of Vaccination Common Form	Form	New

ICR Details

OMB Control No: 3206-0277	ICR Reference No: 202108-3141-002CF
Status: Active	Previous ICR Reference No:
Agency/Subagency: NIGC	Agency Tracking No:
Title: Certification of Vaccine Form (NIGC)
Type of Information Collection: RCF New	Common Form ICR:
Type of Review Request:
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/20/2021
	Date Received in OIRA: 08/20/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2022
Responses	100	0	0
Time Burden (Hours)	3	0	0
Cost Burden (Dollars)	81	0	0

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Abstract:

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Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
   EO: EO 12196 Name/Subject of EO: Occupational Safety and Health Program for Federal Employees
   US Code: 5 USC Chapters 11 and 79
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR?

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

IC Title	Form No.	Form Name
Certification of Vaccination Common Form	3206-0277	Certification of Vaccination Common Form

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ICR Summary of Burden

	Total Approved	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	100	0	0	100	0	0
Annual Time Burden (Hours)	3	0	0	3	0	0
Annual Cost Burden (Dollars)	81	0	0	81	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: The NIGC will use this form to prevent the spread of COVID-19 and to protect the health and safety of all Federal employees, onsite contractors, visitors to Federal Buildings or Federally controlled indoor workspaces, and other individuals interacting with the Federal workforce.

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods?

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.    

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.    

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR: 

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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:

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