USAID PERSONAL SERVICES CONTRACTOR REPORT VACCINATION FORM

ICR 202111-0412-002

OMB: 0412-0614

Federal Form Document

Forms and Documents
IC Document Collections
IC ID
Document
Title
Status
250531 New
ICR Details
202111-0412-002
Received in OIRA
AID
USAID PERSONAL SERVICES CONTRACTOR REPORT VACCINATION FORM
New collection (Request for a new OMB Control Number)   No
Emergency 12/06/2021
11/23/2021
  Requested Previously Approved
6 Months From Approved
3,000 0
750 0
0 0

As required by Executive Order 14042 USAID is implementing the federal COVID-19 vaccination mandate and evaluating compliance by Personal Services Contractors (PSCs). In order to determine compliance, USAID must collect medical information including the number of vaccination doses received, dates, and type of vaccination. Respondents will be USAID PSCs.
USAID must evaluate PSC vaccination documentation to ensure that the information provided complies with Executive Order 14042. USAID proposes to utilize a Report Vaccination Form to collect medical information that will help determine whether PSCs are in compliance with the federal COVID-19 vaccination mandate. The template form is the same as the form used by U.S. Direct Hire (USDH) staff and ensures USAID has the most accurate and current information on contractors’ vaccination status.

EO: EO 14042 Name/Subject of EO: Ensuring Adequate COVID Safety Protocols for Federal Contractors
  
None

Not associated with rulemaking

No

1
IC Title Form No. Form Name
Report Vaccination Form N/A Report Vaccination Form

  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 3,000 0 0 3,000 0 0
Annual Time Burden (Hours) 750 0 0 750 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new requirement.

$0
No
    Yes
    Yes
No
No
No
Yes
Taniesha Tolbert 202 712-1217 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/23/2021


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