Certification of Vaccination Common Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 3206-0277 Certification of Vaccination Common Form	Form	New	Repair queued
PRA Emergency Clearance Letter FINAL.pdf	Supplementary Document	Uploaded 2021-08-05	Repair queued
Supporting Statement Vaccination Attestation Common Form FINAL.docx	Supporting Statement A	Uploaded 2021-08-05	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
248751	Certification of Vaccination Common Form	Form	New

ICR Details

OMB Control No:	ICR Reference No: 202108-3206-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: OPM	Agency Tracking No:
Title: Certification of Vaccination Common Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  Yes
Type of Review Request: Emergency	Approval Requested By: 08/06/2021
Date Submitted to OIRA: 08/05/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	100	0
Time Burden (Hours)	3	0
Cost Burden (Dollars)	81	0

---

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 OPM staff charged with implementing and enforcing workplace safety protocols.

Emergency Justfication: This information must be collected prior to the time periods established under Part 1320 of the regulations and is essential to implement agencies’ health and safety measures included within recent CDC and Safer Federal Workforce Task Force Guidance. Government agencies have an urgent need to request attestation of vaccination status from individuals entering Federal buildings and workspaces. Applying regular PRA clearance procedures is likely to cause harm because of the threat of COVID-19 exposure and transmission.

---

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

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

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

---

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	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: Not applicable.

---

Annual Cost to Federal Government: $841

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.     No

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

---

Common Form ICR:  Yes

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

table that charts list of RCF

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

---

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: 08/05/2021

---