Information Collection

Certification of Vaccination

IC 249212 under ICR 202109-3170-002 · OMB 3170-0075.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3170-0075 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Certification of Vaccination	Form and Instruction
Certification of Vaccination Certification of Vaccination.docx	Form and Instruction
Certification of Vaccination Certification of Vaccination (10-25-2021).docx	Form and Instruction

IC Title:

Certification of Vaccination

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	N/A	Certification of Vaccination	Certification of Vaccination (10-25-2021).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: CFPB.029, Public Health and Safety System

FR Citation: 86 FR 18041

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

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.