Supporting Statement Vaccination Attestation Common Form FINAL

OMB SUPPORTING STATEMENT

Certification of Vaccination Common Form

1. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

Consistent with guidance from the Centers for Disease Control and Prevention (CDC), and guidance from the Safer Federal Workforce Task Force established pursuant to Executive Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), the Office of Personnel Management is establishing specific safety protocols for fully vaccinated people and not fully vaccinated people, respectively.  Individuals who disclose that they are fully vaccinated may comply with agency guidance for fully vaccinated individuals; those who are unvaccinated, are not fully vaccinated, or who choose not to provide this information will be required to comply with CDC and agency guidance for not fully vaccinated individuals, including wearing masks regardless of the transmission rate in a given area, physical distancing, regular testing, and adhering to applicable travel requirements.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

This information is being requested 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.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

Currently, this information collection is paper-based and will require the individual responder to manually fill out a paper form provided at the entrance to an OPM facility and keep the form with them while they are present in an OPM facility. The form may be emailed to respondents who will then print it out to complete it and carry it with them while in an OPM facility. Respondents may also complete the form electronically and save it to their mobile device, which they will then show to agency personnel as requested. We will continue to explore options to use technology to reduce the burden on individuals, however the information itself will be provided directly by the individuals who are attesting to their vaccination status and not collected.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

Similar information certified by the respondents is not available from other sources.

5.  If the collection of information impacts small businesses or other small entities (Item 5 of OMB Form 83-I), describe any methods used to minimize.

This information collection request has no identified impact on small businesses and organizations.

6. Describe the consequence to Federal program or policy activities if the collection of information is not conducted, or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

Less frequent collection would inhibit OPM’s ability to meet the mandates of the Safer Federal Workforce Task Force and OPM’s specific established safety protocols for fully vaccinated people and not fully vaccinated people, respectively.  

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly.

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records, for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secrets, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information’s confidentiality to the extent permitted by law.

Individuals may be required to report information more often than quarterly if their vaccination status changes and they need to update their information or if they routinely seek to enter Federal premises. There are no other special circumstances involved in the collection of this information.

8. Federal Register Notice: Provide a copy and identify the date and page number of the publication in the Federal Register of the agency’s notice soliciting comments on the information collection prior to submission to OMB

OPM has requested and has been granted a waiver from the requirement to publish a notice in the Federal Register in connection with a request for emergency clearance of this information collection request.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No gifts or payments of any kind have been provided to any individuals who are connected to this collection.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

The information collected on this form is not being collected, maintained, or retained by OPM. If that changes, an appropriate Privacy Act statement or other assurance of confidentiality, as appropriate, will be provided and OPM will revise this PRA package.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

This information collection includes a request for information concerning whether an individual has received the COVID-19 vaccination. To the extent this information is deemed sensitive by respondents, it is necessary to promote the safety of Federal buildings, and 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.

12. Provide estimates of the hour burden of the collection of information. The statement
should:

a. Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desired. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB Form 83-I.

c. Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

Given the current occupancy restrictions in OPM facilities, the maximum telework posture in which OPM is operating, and the restriction on visitors in OPM facilities, the number of forms that will be processed within the next six months is estimated to be 100. The form requires approximately 2 minutes for completion and, therefore, a burden of 3 hours and 20 minutes is estimated during the six-month period covered by this emergency clearance request.

Type of Respondent	Form Name	No. of Respondents	No. of Responses per Respondent	Total No. of Responses within 6 months	Avg. Burden per Response (in hours)	Total Annual Burden (in hours)
Visitors or Federal Contractors	Email or paper certification	100	1	100	.03	3.33

13. Provide an estimate of the total annual cost burden to respondents or record-keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14.)

The cost estimate should be split into two components: (1) a total capital and start-up cost component (annualized over its expected useful life); and (b) a total operation and maintenance and purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection as appropriate.

Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information to keep records for the government, or (4) as part of customary and usual business or private practices.

Type of Respondent	Form Name	No. of Respondents	Total No. of Responses within 6 month approval	Avg. Burden per Response (in hours)	Hourly Wage Rate	Total Respondent Costs
Visitors and Federal Contractors	Certification of Vaccination Common Form	100	1	.03	$27.07	$81.21

The estimated total cost to respondents is $81.21. This is based on an estimated hourly wage of $27.07/hour using the all occupations, non-managerial line item. The salary estimates were based on U.S. Department of Labor estimated mean hourly rates in the United States in May 2020.

No other costs, including capital or maintenance costs, will be incurred by respondents, beyond their time.

14. Provide estimates of annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing and support staff), and any other expense that would have been incurred without this collection of information. You may also aggregate cost estimates for Items 12, 13, and 14 in a single table.

The annualized cost to the Federal government is estimated to be $841.04. This cost includes 14 employee salary hours related to design and preparation of the form, printing, and distribution to OPM facilities.

Expense Type	Expense Explanation	Hours	Hourly Wage (dollars)	Annual Costs (dollars)
OPM Costs	1 staff at GS-14, step 5	7	51	357
OPM Costs	1 staff at GS-13, step 5	5	43.15	215.75
OPM Costs	1 staff at SL	2	89.43	268.29
TOTAL				841.04

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I. Changes in hour burden, i.e., program changes or adjustments made to annual reporting and recordkeeping hour and cost burden. A program change is the result of deliberate Federal government action. All new collections and any subsequent revisions of existing collections (e.g., the addition or deletion of questions) are recorded as program changes. An adjustment is a change that is not the result of a deliberate Federal government action. These changes that result from new estimates or actions not controllable by the Federal government are recorded as adjustments.

This is a new emergency collection and thus this is not applicable.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

Not applicable. This information will not be collected or maintained.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain reasons that display would be inappropriate.

Not applicable. Display of OMB Control Number and expiration date is acceptable.

18. Explain each exception to the certification statement identified in Item 19 “Certification for Paperwork Reduction Act Submissions,” of OMB Form 83-I.

Not applicable.