Student Vaccination Certification and Testing Consent

COVID-19 Symptom Tracker for Students, Emotional Wellness Form for Students, and Student Vaccination Status and Test Consent Form Collection

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0548 can be found here:

Documents and Forms

Document Name Document Type
1205-0NEW Attachment C COVID Vaccine Collect Form 9.20.2021 OJC.docx Other-Attestation
1205-0NEW Attachment C COVID Vaccine Collect Form 9.20.2021 OJC.docx Other-Attestation

Information Collection (IC) Details

IC Title:	Student Vaccination Certification and Testing Consent	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Attestation			1205-0NEW Attachment C COVID Vaccine Collect Form 9.20.2021 OJC.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40,000	40,000
Annual IC Time Burden (Hours)	13,200	13,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.