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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.