Information Collection

Certification of Vaccination Common Form

IC 249463 under ICR 202109-0420-001CF · OMB 3206-0277.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0277 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3206-0277 Certification of Vaccination Common Form	Form
3206-0277 Certification of Vaccination Common Form CertificationVaccinationPRAv6.pdf	Form
OPM 5062 Certification Vaccination Employee CertificationVaccinationEmployeesFinal.pdf	Form and Instruction
3206-0277 Certification Vaccination PRA CertificationVaccinationPRAfinal.pdf	Form and Instruction

IC Title:

Certification of Vaccination Common Form

Agency IC Tracking Number:

PC-3011

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3206-0277	Certification of Vaccination Common Form	CertificationVaccinationPRAv6.pdf	No		Printable Only
Form and Instruction	OPM 5062	Certification Vaccination Employee	CertificationVaccinationEmployeesFinal.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	3206-0277	Certification Vaccination PRA	CertificationVaccinationPRAfinal.pdf	Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records

Title: OPM/GOVT-10

FR Citation: 80 FR 74815

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	81	81

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.