Certification of Vaccination

Forms and Documents

Document Name	Status
Certification of Vaccination Form and Instruction	New
Certification of Vaccination Supporting Statement.docx Supporting Statement A	2021-09-14
Emergency Clearance Memorandum (Certification of Vaccination).pdf Supplementary Document	2021-09-08

IC Document Collections

IC ID	Document Title	Status
249212	Certification of Vaccination Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202109-3170-002
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: CFPB	Agency Tracking No:
Title: Certification of Vaccination
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 09/22/2021
Date Submitted to OIRA: 09/14/2021

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	1,500	0
Time Burden (Hours)	125	0
Cost Burden (Dollars)	0	0

---

Abstract: The Consumer Financial Protection Bureau (CFPB or the Bureau) is establishing safety protocols for both fully vaccinated and unvaccinated people. This information collection (e.g. the certification form) will ascertain individuals’ vaccination status in order for the Bureau to comply with Executive Order 13991 titled Protecting the Federal Workforce and Requiring Mask-Wearing. In compliance with guidance from the Centers for Disease Control and Prevention (CDC) and the Safer Federal Workforce Task Force, the Bureau is collecting this information from fully vaccinated individuals so that they can comply with Bureau safety guidelines. The Bureau is also collecting this information from partially or unvaccinated individuals so that that other measures can be implemented to enforce Bureau safety guidelines (e.g. wearing masks, physical/social distancing, regular testing, adherence to applicable travel requirements). The Bureau requests these data 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, Bureau staff will use these data for implementing and enforcing workplace safety protocols.

Emergency Justfication: On January 20, 2021, the President signed Executive Order 13991 (titled “Protecting the Federal Workforce and Requiring Mask-Wearing”) in order to stop the spread of coronavirus disease by relying on the best available data and science-based public health measures. Vaccines, masks, and other known public health measures help to reduce the spread of coronavirus when affected communities employ them. The Bureau requests the approval of this vaccination attestation to protect the Federal workforce and individuals directly interacting with the Federal workforce while ensuring continuity of government service. This attestation will collect data on the vaccination status of Federal employees, Federal contractors, and any members of the public requesting physical access to the Bureau. Failure to collect these data will result in diminished effectiveness of science-based public health measures and likely result in public harm. Per 5 Code of Federal Regulations Part 1320.13, the Bureau is requesting emergency processing of this submission due to: • The certification being essential to safe operations within the Bureau; and • The likely public harm that will result if normal clearance procedures are followed by Bureau staff.

---

Authorizing Statute(s): None

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

IC Title	Form No.	Form Name
Certification of Vaccination	N/A	Certification of Vaccination

---

ICR Summary 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	1,500	0	0	1,500	0	0
Annual Time Burden (Hours)	125	0	0	125	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: This ICR is requesting emergency processing of a new information collection. There are no program changes nor adjustments.

---

Annual Cost to Federal Government: $0

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.     Yes

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:  No

---

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: 09/14/2021

---