Supporting Statement - USPSC Vaccine Documentation

Title:‌ U
‌ SAID‌‌PERSONAL‌‌SERVICES‌‌CONTRACTOR‌‌DOCUMENTATION‌‌FORM‌‌FOR‌‌THE‌‌

COVID-19‌‌VACCINATION‌‌REQUIREMENT‌  ‌
Form‌‌names‌‌and‌‌numbers:‌ U
‌ SAID‌‌PERSONAL‌‌SERVICES‌‌CONTRACTOR‌‌REPORT‌‌

VACCINATION‌‌FORM‌  ‌
OMB‌‌Control‌‌Number:‌‌‌0412‌‌-‌‌xxxxxx‌  ‌
PART‌‌A.‌‌JUSTIFICATION‌   ‌ ‌
1.‌‌Explain‌‌the‌‌circumstances‌‌that‌‌make‌‌the‌‌collection‌‌of‌‌information‌‌necessary.‌   ‌ ‌
This‌‌information‌‌is‌‌being‌‌collected‌‌and‌‌maintained‌‌to‌‌promote‌‌the‌‌safety‌‌of‌‌Federal‌‌workplaces‌‌and‌‌the‌‌ 
Federal‌‌workforce‌‌consistent‌‌with‌‌Executive‌‌Order‌‌14042,‌‌Executive‌‌Order‌‌13991,‌‌Protecting‌‌the‌‌Federal‌‌ 
Workforce‌‌and‌‌Requiring‌‌Mask-Wearing‌‌(Jan.‌‌20,‌‌2021),‌‌the‌‌COVID-19‌‌Workplace‌‌Safety:‌‌Agency‌‌ 
Model‌‌Safety‌‌Principles‌‌established‌‌by‌‌the‌‌Safer‌‌Federal‌‌Workforce‌‌Task‌‌Force,‌‌and‌‌guidance‌‌from‌‌ 
Centers‌‌for‌‌Disease‌‌Control‌‌and‌‌Prevention‌‌and‌‌the‌‌Occupational‌‌Safety‌‌and‌‌Health‌‌Administration.‌‌ 
Government-wide‌‌policy‌‌requires‌‌all‌‌USAID‌‌Personal‌‌Services‌‌Contractors‌‌(PSCs)‌‌to‌‌be‌‌vaccinated‌‌ 
against‌‌COVID-19,‌‌with‌‌exceptions‌‌only‌‌as‌‌required‌‌by‌‌law.‌   ‌
As‌‌required,‌‌USAID‌‌is‌‌implementing‌t‌ he‌‌federal‌‌COVID-19‌‌vaccination‌‌mandate‌‌and‌‌requiring‌P
‌ SC‌ 
staff‌‌to‌‌be‌‌vaccinated,‌‌unless‌‌they‌‌have‌‌an‌‌approved‌‌exception.‌ ‌Since‌‌the‌‌collection‌‌of‌‌medical‌‌ 
information‌‌is‌‌required‌‌in‌‌order‌‌to‌‌determine‌‌whether‌‌PSC‌‌staff‌‌are‌‌in‌‌compliance,‌‌USAID‌‌proposes‌‌to‌‌ 
utilize‌‌a‌‌Report‌‌Vaccination‌‌Form.‌ ‌The‌‌template‌‌form‌‌is‌‌the‌‌same‌‌as‌‌the‌‌form‌‌used‌‌by‌‌U.S.‌‌Direct‌‌Hire‌‌ 
(USDH)‌‌staff‌‌and‌‌ensures‌‌USAID‌‌has‌‌the‌‌most‌‌accurate‌‌and‌‌current‌‌information‌‌on‌‌contractors’‌‌ 
vaccination‌‌status.‌‌The‌‌form‌‌requires‌‌the‌‌PSC‌‌staff‌‌to‌‌submit‌‌information‌‌indicating‌‌the‌‌number‌‌of‌‌ 
vaccination‌‌doses‌‌received,‌‌date(s),‌‌and‌‌type‌‌of‌‌vaccination.‌‌All‌‌USAID‌‌PSCs,‌‌unless‌‌they‌‌have‌‌ 
submitted‌‌an‌‌exception‌‌request,‌‌are‌‌required‌‌to‌‌complete‌‌a‌‌Report‌‌Vaccination‌‌Form.‌  ‌
 ‌
The‌‌proposed‌‌form‌‌requests‌‌applicant‌‌submit‌‌the‌‌following‌‌information‌‌from‌‌their‌‌COVID-19‌‌ 
vaccination:‌  ‌
1.
The‌‌date(s)‌‌of‌‌the‌‌COVID-19‌‌vaccination;‌  ‌
2.
The‌‌total‌‌number‌‌of‌‌COVID-19‌‌vaccination‌‌doses;‌‌and,‌  ‌
3.
The‌‌type(s)‌‌of‌‌vaccination‌‌administered.‌‌   ‌
 ‌
The‌‌collection‌‌of‌‌this‌‌medical‌‌information‌‌is‌‌necessary‌‌to‌‌sufficiently‌‌evaluate‌‌and‌‌make‌‌determinations‌‌ 
on‌‌compliance‌‌with‌t‌ he‌‌federal‌‌COVID-19‌‌vaccination‌‌mandate.‌   ‌ ‌
 ‌
2.‌‌Indicate‌‌how,‌‌by‌‌whom,‌‌and‌‌for‌‌what‌‌purpose‌‌the‌‌information‌‌is‌‌to‌‌be‌‌used.‌‌Except‌  ‌
for‌‌a‌‌new‌‌collection,‌‌indicate‌‌the‌‌actual‌‌use‌‌the‌‌agency‌‌has‌‌made‌‌of‌‌the‌‌information‌  ‌
received‌‌from‌‌the‌‌current‌‌collection.‌   ‌ ‌
 ‌
In‌‌accordance‌‌with‌‌Executive‌‌Order‌‌14042‌‌(Ensuring‌‌Adequate‌‌COVID‌‌Safety‌‌Protocols‌‌for‌‌

Federal‌‌Contractors)‌,‌‌USAID‌‌is‌‌implementing‌‌the‌‌federal‌‌vaccine‌‌mandate‌‌for‌‌its‌‌PSC‌‌

workforce‌‌and‌‌reviewing‌‌contractors’‌‌submission‌‌of‌‌vaccination‌‌documentation.‌‌
   ‌
 ‌
3.‌‌Describe‌‌whether,‌‌and‌‌to‌‌what‌‌extent,‌‌the‌‌collection‌‌of‌‌information‌‌involves‌‌the‌‌use‌‌of‌  ‌
automated,‌‌electronic,‌‌mechanical,‌‌or‌‌other‌‌technological‌‌collection‌‌techniques‌‌or‌‌other‌  ‌
forms‌‌of‌‌information‌‌technology.‌   ‌ ‌
The‌‌form‌‌is‌‌in‌‌electronic‌‌fillable‌‌format.‌‌All‌‌forms‌‌must‌‌be‌‌submitted‌‌electronically‌‌via‌‌the‌‌Agency‌‌

LaunchPad‌‌system.‌‌Given‌‌the‌‌U.S.‌‌Agency‌‌for‌‌International‌‌Development’s‌‌continued‌‌mandatory‌‌

telework‌‌status,‌‌in-person‌‌paper‌‌submissions‌‌or‌‌mailing‌‌to‌‌Agency‌‌headquarters‌‌are‌‌not‌‌possible.‌‌

Moreover,‌‌electronic‌‌submission‌‌is‌‌an‌‌improved‌‌form‌‌of‌‌information‌‌technology‌‌that‌‌reduces‌‌the‌‌

burden‌‌on‌‌users.‌  ‌
The‌‌form‌‌is‌‌a‌‌part‌‌of‌‌an‌‌internal‌‌process‌‌to‌‌review‌‌contractor‌‌compliance‌‌with‌‌the‌‌COVID-19‌‌

vaccine‌‌requirement‌‌requests‌‌and‌‌as‌‌such,‌‌is‌‌not‌‌available‌‌to‌‌the‌‌general‌‌public.‌‌Additionally,‌‌due‌‌to‌‌

the‌‌nature‌‌of‌‌the‌‌collected‌‌material,‌‌results‌‌of‌‌the‌‌information‌‌collected‌‌will‌‌not‌‌be‌‌made‌‌available‌‌to‌‌

the‌‌public.‌‌
   ‌
 ‌
4.‌  ‌Describe‌‌
  efforts‌‌
  to‌‌
  identify‌‌
  duplication.‌‌
  Show‌‌
  specifically‌‌
  why‌‌
  any‌‌
  similar‌‌
  information‌  ‌
already‌‌
  available‌‌
  cannot‌‌
  be‌‌
  used‌‌
  or‌‌
  modified‌‌
  for‌‌
  use‌‌
  for‌‌
  the‌‌
 purposes‌‌
 described‌‌
 in‌‌
 item‌‌
 2 ‌ ‌
above.‌   ‌ ‌
Given‌‌the‌‌federal‌‌COVID-19‌‌vaccine‌‌requirement‌‌was‌‌mandated‌‌on‌‌September‌‌9,‌‌2021,‌‌the‌‌

Agency‌‌does‌‌not‌‌already‌‌have‌‌up-to-date‌‌medical‌‌information‌‌on‌‌contractors‌‌related‌‌to‌‌the‌‌

COVID-19‌‌vaccine‌‌that‌‌is‌‌sufficient‌‌to‌‌ensure‌‌compliance‌‌without‌‌additional‌‌information‌‌

requests.‌‌
   ‌
 ‌
5.‌‌If‌‌the‌‌collection‌‌of‌‌information‌‌impacts‌‌small‌‌businesses‌‌or‌‌other‌‌small‌‌entities,‌‌describe‌  ‌
any‌‌methods‌‌used‌‌to‌‌minimize‌‌burden.‌   ‌ ‌
 ‌
The‌‌collection‌‌should‌‌not‌‌impact‌‌other‌‌small‌‌businesses‌‌or‌‌other‌‌small‌‌entities.‌‌
   ‌
 ‌
6.‌‌Describe‌‌the‌‌consequence‌‌to‌‌Federal‌‌program‌‌or‌‌policy‌‌activities‌‌if‌‌the‌‌collection‌‌is‌‌not‌  ‌
conducted‌‌or‌‌is‌‌conducted‌‌less‌‌frequently,‌‌as‌‌well‌‌as‌‌any‌‌technical‌‌or‌‌legal‌‌obstacles‌‌to‌  ‌
reducing‌‌the‌‌burden.‌   ‌
If‌‌the‌‌medical‌‌information‌‌is‌‌not‌‌collected,‌‌the‌‌Agency‌‌cannot‌‌determine‌‌if‌‌its‌‌PSC‌‌

staff‌‌are‌‌in‌‌compliance‌‌with‌‌the‌‌federal‌‌COVID-19‌‌vaccine‌‌requirement.‌   ‌ ‌
Additionally,‌‌the‌‌proposed‌‌form‌‌allows‌‌for‌‌the‌‌uniform‌‌collection‌‌of‌‌information‌‌

predetermined‌‌to‌‌be‌‌necessary‌‌for‌‌evaluation.‌‌Uniform‌‌collection‌‌is‌‌critical‌‌to‌‌ensure‌‌

all‌‌cases‌‌are‌‌evaluated‌‌and‌‌processed‌‌in‌‌the‌‌same‌‌way.‌‌
   ‌

Collection‌‌is‌‌currently‌‌only‌‌required‌‌once‌‌and‌‌as‌‌such,‌‌cannot‌‌be‌‌conducted‌‌less‌‌

frequently.‌   ‌ ‌
 ‌
7.‌‌Special‌‌Circumstances‌   ‌ ‌
 ‌
There‌‌are‌‌no‌‌special‌‌circumstances‌‌that‌‌would‌‌cause‌‌the‌‌information‌‌collected‌‌to‌‌be‌‌

conducted‌‌in‌‌a‌‌manner:‌  ‌
●
requiring‌‌respondents‌‌to‌‌report‌‌information‌‌to‌‌the‌‌agency‌‌more‌‌often‌‌than‌‌quarterly;‌‌
   ‌
●
requiring‌‌respondents‌‌to‌‌prepare‌‌a‌‌written‌‌response‌‌to‌‌a‌‌collection‌‌of‌‌information‌‌in‌‌

fewer‌‌than‌‌30‌‌days‌‌after‌‌receipt‌‌of‌‌it;‌   ‌ ‌
●
requiring‌‌respondents‌‌to‌‌submit‌‌more‌‌than‌‌an‌‌original‌‌and‌‌two‌‌copies‌‌of‌‌any‌‌

document;‌‌
   ‌
●
requiring‌‌respondents‌‌to‌‌retain‌‌records,‌‌other‌‌than‌‌health,‌‌medical,‌‌government‌‌

contract,‌ ‌grant-in-aid,‌‌or‌‌tax‌‌records,‌‌for‌‌more‌‌than‌‌3‌‌years.‌  ‌
●
in‌‌connection‌‌with‌‌a‌‌statistical‌‌survey,‌‌that‌‌is‌‌not‌‌designed‌‌to‌‌produce‌‌valid‌‌and‌‌

reliable‌‌results‌‌that‌‌can‌‌be‌‌generalized‌‌to‌‌the‌‌universe‌‌of‌‌study;‌   ‌ ‌
●
requiring‌‌the‌‌use‌‌of‌‌a‌‌statistical‌‌data‌‌classification‌‌that‌‌has‌‌not‌‌been‌‌reviewed‌‌and‌‌

approved‌‌by‌‌OMB;‌   ‌ ‌
●
that‌‌includes‌‌a‌‌pledge‌‌of‌‌confidentiality‌‌that‌‌is‌‌not‌‌supported‌‌by‌‌authority‌‌

established‌‌in‌‌statute‌‌or‌‌regulation,‌‌that‌‌is‌‌not‌‌supported‌‌by‌‌disclosure‌‌and‌‌data‌‌security‌‌

policies‌‌that‌‌are‌‌consistent‌‌with‌‌the‌‌pledge,‌‌or‌‌which‌‌unnecessarily‌‌impedes‌‌sharing‌‌of‌‌data‌‌

with‌‌other‌‌agencies‌‌for‌‌compatible‌‌confidential‌‌use;‌‌or‌   ‌ ‌
●
requiring‌‌respondents‌‌to‌‌submit‌‌proprietary‌‌trade‌‌secrets,‌‌or‌‌other‌‌confidential‌‌information‌‌

unless‌‌the‌‌agency‌‌can‌‌demonstrate‌‌that‌‌it‌‌has‌‌instituted‌‌procedures‌‌to‌‌protect‌‌the‌‌information's‌‌

confidentiality‌‌to‌‌the‌‌extent‌‌permitted‌‌by‌‌law.‌‌Please‌‌see‌‌item‌‌10‌‌for‌‌information‌‌on‌‌how‌‌the‌‌agency‌‌

has‌‌instituted‌‌procedures‌‌to‌‌protect‌‌respondents’‌‌information.‌‌
   ‌
 ‌
8.‌‌If‌‌applicable,‌‌provide‌‌a‌‌copy‌‌and‌‌identify‌‌the‌‌date‌‌and‌‌page‌‌number‌‌of‌‌publication‌‌in‌‌the‌  ‌
Federal‌‌Register‌‌of‌‌the‌‌agency's‌‌notice,‌‌required‌‌by‌‌5‌‌CFR‌‌1320.8(d),‌‌soliciting‌‌comments‌‌on‌  ‌
the‌‌information‌‌collection‌‌prior‌‌to‌‌submission‌‌to‌‌OMB.‌   ‌ ‌
In‌‌the‌‌Justification‌‌Statement‌‌included‌‌in‌‌this‌‌emergency‌‌approval‌‌request,‌‌USAID‌‌is‌‌requesting‌‌

OIRA‌‌approval‌‌to‌‌not‌‌publish‌‌a‌‌Federal‌‌Register‌‌notice‌‌in‌‌association‌‌with‌‌this‌‌form.‌  ‌
 ‌
9.‌‌Explain‌‌any‌‌decision‌‌to‌‌provide‌‌any‌‌payment‌‌or‌‌gift‌‌to‌‌respondents,‌‌other‌‌than‌  ‌
remuneration‌‌of‌‌contractors‌‌or‌‌grantees.‌   ‌ ‌
Payment‌‌or‌‌gifts‌‌will‌‌not‌‌be‌‌provided‌‌to‌‌respondents.‌‌
   ‌
 ‌
10.‌‌Describe‌‌any‌‌assurance‌‌of‌‌confidentiality‌‌provided‌‌to‌‌respondents‌‌and‌‌the‌‌basis‌‌for‌‌the‌  ‌
assurance‌‌in‌‌statute,‌‌regulation,‌‌or‌‌agency‌‌policy.‌   ‌ ‌

The‌‌Privacy‌‌Act‌‌(5‌‌U.S.C.‌‌552a)‌‌applies‌‌to‌‌this‌‌collection‌‌and‌‌is‌‌used‌‌as‌‌a‌‌statutory‌‌authority‌‌for‌‌

confidentiality.‌T
‌ he‌‌authorities‌‌for‌‌the‌‌system‌‌of‌‌records‌‌notices‌‌(SORNs)‌‌associated‌‌with‌‌this‌‌ 
collection‌‌of‌‌information‌‌is‌U
‌ SAID-34,‌‌Personal‌‌Services‌‌Contracts‌‌Records,‌‌80‌‌FR‌‌11391‌‌(March‌‌3,‌‌ 
2015)‌. ‌ ‌
While‌‌the‌‌information‌‌requested‌‌is‌‌intended‌‌to‌‌be‌‌used‌‌primarily‌‌for‌‌internal‌‌purposes,‌‌in‌‌certain‌‌ 
circumstances‌‌it‌‌may‌‌be‌‌necessary‌‌to‌‌disclose‌‌this‌‌information‌‌externally,‌‌for‌‌example‌‌to‌‌disclose‌‌ 
information‌‌to:‌‌a‌‌Federal,‌‌State,‌‌or‌‌local‌‌agency‌‌to‌‌the‌‌extent‌‌necessary‌‌to‌‌comply‌‌with‌‌laws‌‌governing‌‌ 
reporting‌‌of‌‌communicable‌‌disease‌‌or‌‌other‌‌laws‌‌concerning‌‌health‌‌and‌‌safety‌‌in‌‌the‌‌work‌‌environment;‌‌ 
to‌‌adjudicative‌‌bodies‌‌(e.g.,‌‌the‌‌Merit‌‌System‌‌Protection‌‌Board),‌‌arbitrators,‌‌and‌‌hearing‌‌examiners‌‌to‌‌ 
the‌‌extent‌‌necessary‌‌to‌‌carry‌‌out‌‌their‌‌authorized‌‌duties‌‌regarding‌‌Federal‌‌employment;‌‌to‌‌contractors,‌‌ 
grantees,‌‌or‌‌volunteers‌‌as‌‌necessary‌‌to‌‌perform‌‌their‌‌duties‌‌for‌‌the‌‌Federal‌‌Government;‌‌to‌‌other‌‌ 
agencies,‌‌courts,‌‌and‌‌persons‌‌as‌‌necessary‌‌and‌‌relevant‌‌in‌‌the‌‌course‌‌of‌‌litigation,‌‌and‌‌as‌‌necessary‌‌and‌‌ 
in‌‌accordance‌‌with‌‌requirements‌‌for‌‌law‌‌enforcement;‌‌or‌‌to‌‌a‌‌person‌‌authorized‌‌to‌‌act‌‌on‌‌your‌‌behalf.‌‌A ‌‌
complete‌‌list‌‌of‌‌the‌‌routine‌‌uses‌‌can‌‌be‌‌found‌‌in‌‌the‌‌SORN‌‌associated‌‌with‌‌this‌‌collection‌‌of‌‌ 
information,‌‌USAID-34,‌‌Personal‌‌Services‌‌Contracts‌‌Records,‌‌80‌‌FR‌‌11391‌‌(March‌‌3,‌‌2015).‌  ‌
 ‌
11.‌‌Provide‌‌additional‌‌justification‌‌for‌‌any‌‌questions‌‌of‌‌a‌‌sensitive‌‌nature,‌‌such‌‌as‌‌sexual‌  ‌
behavior‌‌and‌‌attitudes,‌‌religious‌‌beliefs,‌‌and‌‌other‌‌matters‌‌that‌‌are‌‌commonly‌‌considered‌  ‌
private‌. ‌  ‌ ‌
 ‌
As‌‌outlined‌‌in‌‌Section‌E
‌ .‌‌(Pandemic-Related‌‌Harassment‌‌Due‌‌to‌‌National‌‌Origin,‌‌Race,‌‌or‌‌Other‌‌ 
Protected‌‌Characteristics)‌‌of‌‌the‌‌U.S.‌‌Equal‌‌Employment‌‌Opportunity‌‌Commission’s‌W
‌ hat‌‌You‌‌ 
Should‌‌Know‌‌About‌‌COVID-19‌‌and‌‌the‌‌ADA,‌‌the‌‌Rehabilitation‌‌Act,‌‌and‌‌Other‌‌EEO‌‌Laws‌,‌‌it‌‌is‌‌ 
against‌‌the‌‌federal‌‌Equal‌‌Employment‌‌Opportunity‌‌laws‌‌to‌‌harass‌‌or‌‌otherwise‌‌discriminate‌‌against‌‌ 
coworkers‌‌based‌‌on‌‌race,‌‌national‌‌origin,‌‌color,‌‌sex,‌‌religion,‌‌age‌‌(40‌‌or‌‌over),‌‌disability,‌‌or‌‌genetic‌‌ 
information.‌   ‌
 ‌
The‌‌form‌‌includes‌‌the‌‌following‌‌information,‌‌informing‌‌people‌‌from‌‌whom‌‌the‌‌information‌‌is‌‌ 
requested‌‌on‌‌why‌‌the‌‌information‌‌is‌‌being‌‌requested,‌‌how‌‌it‌‌will‌‌be‌‌used,‌‌and‌‌consequences‌‌for‌‌not‌‌ 
providing‌‌the‌‌information:‌  ‌
 ‌
Authority:‌P
‌ ursuant‌‌to‌‌5‌‌U.S.C.‌‌chapters‌‌11‌‌and‌‌79,‌‌and‌‌in‌‌discharging‌‌the‌‌functions‌‌directed‌‌ 
under‌‌Executive‌‌Order‌‌14043,‌‌Requiring‌‌Coronavirus‌‌Disease‌‌2019‌‌Vaccination‌‌for‌‌Federal‌‌ 
Employees‌‌(Sept.‌‌9,‌‌2021)‌‌and‌‌Executive‌‌Order‌‌14042‌ ‌(Ensuring‌‌Adequate‌‌COVID‌‌Safety‌‌ 
Protocols‌‌for‌‌Federal‌‌Contractors),‌‌we‌‌are‌‌authorized‌‌with‌‌this‌‌collection‌‌of‌‌information,‌‌ 
OP‌M/‌GOVT-10,‌‌Employee‌‌Medical‌‌File‌‌System‌‌of‌‌Records‌,‌‌75‌ ‌‌Fed.‌‌Reg.‌‌35099‌‌(June‌‌21,‌‌2010,‌ 
amended‌‌80‌‌Fed.‌‌Reg.‌7‌ 4‌ 815‌‌(Nov.‌‌30,‌‌2015),‌‌also‌‌includes‌‌5‌‌U.S.C.‌‌chapters‌‌33‌‌and‌‌63‌‌and‌‌ 
Executive‌‌Order‌‌12196,‌‌Occupational‌‌Safety‌‌and‌‌Health‌‌Program‌‌for‌‌Federal‌‌Employees‌‌(Feb.‌‌ 
26,‌‌1980)‌‌and‌U
‌ SAID-34,‌‌Personal‌‌Services‌‌Contracts‌‌Records,‌‌80‌‌FR‌‌11391‌‌(March‌‌3,‌‌2015)‌. ‌ ‌
Providing‌‌this‌‌information‌‌is‌‌mandatory,‌‌and‌‌we‌‌are‌‌authorized‌‌to‌‌impose‌‌penalties‌‌for‌‌failure‌‌to‌‌ 
provide‌‌the‌‌information‌‌pursuant‌‌to‌‌applicable‌‌Federal‌‌personnel‌‌laws‌‌and‌‌regulations.‌‌   ‌
 ‌

Purpose:‌T
‌ his‌‌information‌‌is‌‌being‌‌collected‌‌and‌‌maintained‌‌to‌‌promote‌‌the‌‌safety‌‌of‌‌Federal‌‌ 
buildings‌‌and‌‌the‌‌Federal‌‌workforce‌‌consistent‌‌with‌‌the‌‌above-referenced‌‌authorities,‌‌Executive‌‌ 
Order‌‌13991,‌‌Protecting‌‌the‌‌Federal‌‌Workforce‌‌and‌‌requiring‌‌Mask-Wearing‌‌(Jan.‌‌20,‌‌2021),‌‌the‌‌ 
COVID-19‌‌Workplace‌‌Safety‌‌Plan‌‌and‌‌Workplace‌‌Guidelines:‌‌Agency‌‌Model‌‌Safety‌‌Principles‌‌ 
established‌‌by‌‌the‌‌Safer‌‌Federal‌‌Workforce‌‌Task‌‌Force,‌‌and‌‌guidance‌‌from‌‌Centers‌‌for‌‌Disease‌‌ 
Control‌‌and‌‌Prevention‌‌and‌‌the‌‌Occupational‌‌Safety‌‌and‌‌Health‌‌Administration.‌‌   ‌
 ‌
Routine‌‌Uses:‌‌‌While‌‌the‌‌information‌‌requested‌‌is‌‌intended‌‌to‌‌be‌‌used‌‌primarily‌‌for‌‌internal‌‌ 
purposes,‌‌in‌‌certain‌‌circumstances‌‌it‌‌may‌‌be‌‌necessary‌‌to‌‌disclose‌‌this‌‌information‌‌externally,‌‌for‌‌ 
example‌‌to‌‌disclose‌‌information‌‌to:‌‌a‌‌Federal,‌‌State,‌‌or‌‌local‌‌agency‌‌to‌‌the‌‌extent‌‌necessary‌‌to‌‌ 
comply‌‌with‌‌laws‌‌governing‌‌reporting‌‌of‌‌communicable‌‌disease‌‌or‌‌other‌‌laws‌‌concerning‌‌health‌‌ 
and‌‌safety‌‌in‌‌the‌‌work‌‌environment;‌‌to‌‌adjudicative‌‌bodies‌‌(e.g.,‌‌the‌‌Merit‌‌System‌‌Protection‌‌ 
Board),‌‌arbitrators,‌‌and‌‌hearing‌‌examiners‌‌to‌‌the‌‌extent‌‌necessary‌‌to‌‌carry‌‌out‌‌their‌‌authorized‌‌ 
duties‌‌regarding‌‌Federal‌‌employment;‌‌to‌‌contractors,‌‌grantees,‌‌or‌‌volunteers‌‌as‌‌necessary‌‌and‌‌ 
relevant‌‌in‌‌the‌‌course‌‌of‌‌litigation,‌‌and‌‌as‌‌necessary‌‌and‌‌in‌‌accordance‌‌with‌‌requirements‌‌for‌‌law‌‌ 
enforcement;‌‌or‌‌to‌‌a‌‌person‌‌authorized‌‌to‌‌act‌‌on‌‌your‌‌behalf.‌‌A‌‌complete‌‌list‌‌of‌‌the‌‌routine‌‌uses‌‌ 
can‌‌be‌‌found‌‌in‌‌the‌‌SORN‌‌associated‌‌with‌‌this‌‌collection‌‌of‌‌information.‌‌   ‌
 ‌
Consequence‌‌of‌‌Failure‌‌to‌‌provide‌‌Information:‌P
‌ roviding‌‌this‌‌information‌‌is‌‌mandatory.‌‌ 
Unless‌‌granted‌‌a‌‌legally‌‌required‌‌exception,‌‌all‌‌covered‌‌Federal‌‌employees‌‌are‌‌required‌‌to‌‌be‌‌ 
vaccinated‌‌against‌‌COVID-19‌‌and‌‌to‌‌provide‌‌documentation‌‌concerning‌‌their‌‌vaccination‌‌status‌‌ 
to‌‌their‌‌employing‌‌agency.‌‌Unless‌‌you‌‌have‌‌been‌‌granted‌‌a‌‌legally‌‌required‌‌exception,‌‌failure‌‌to‌‌ 
provide‌‌this‌‌information‌‌may‌‌subject‌‌you‌‌to‌‌disciplinary‌‌action,‌‌including‌‌and‌‌up‌‌to‌‌removal‌‌from‌‌ 
Federal‌‌service.‌‌   ‌
 ‌
12.‌‌Provide‌‌estimates‌‌of‌‌the‌‌hour‌‌burden‌‌of‌‌the‌‌collection‌‌of‌‌information.‌‌
   ‌

The‌‌hour‌‌burden‌‌is‌‌not‌‌expected‌‌to‌‌vary‌‌widely.‌‌The‌‌amount‌‌of‌‌requested‌‌information‌‌from‌‌each‌‌ 
individual‌‌is‌‌the‌‌same.‌   ‌ ‌
 ‌
Form‌   ‌ ‌
Name‌  ‌

USAID‌‌

PERSONAL‌‌

SERVICES‌‌

CONTRACTOR‌‌

REPORT‌‌

VACCINATION‌‌

FORM‌  ‌
 ‌

Form‌   ‌ ‌
Number‌  ‌

No.‌‌of‌   ‌ ‌
Respondents‌  ‌

 ‌
3000‌  ‌
0412-‌
xxxxx‌  ‌

No.‌‌of‌   ‌ ‌
Responses‌ ‌per‌   ‌ ‌
Respondent‌  ‌

One‌  ‌

Average.‌   ‌ ‌
Burden‌   ‌ ‌
per‌   ‌ ‌
Response‌   ‌ ‌
(in‌‌hours)‌  ‌

.25‌‌hour‌  ‌

Total‌   ‌ ‌
Annual‌   ‌ ‌
Burden‌‌(in‌  ‌
hours)‌  ‌

750‌  ‌

13.‌‌Provide‌‌an‌‌estimate‌‌for‌‌the‌‌total‌‌annual‌‌cost‌‌burden‌‌to‌‌respondents‌‌or‌‌record-keepers‌  ‌
resulting‌‌from‌‌the‌‌collection‌‌of‌‌information.‌‌
   ‌
 ‌
A‌‌total‌‌capital‌‌and‌‌start-up‌‌cost‌‌component‌‌(annualized‌‌over‌‌its‌‌expected‌‌useful‌‌life):‌‌none.‌  ‌
A‌‌total‌‌operation‌‌and‌‌maintenance‌‌and‌‌purchase‌‌of‌‌services‌‌component:‌‌none.‌  ‌
 ‌
14.‌‌Provide‌‌estimates‌‌of‌‌annualized‌‌costs‌‌to‌‌the‌‌Federal‌‌Government.‌   ‌ ‌
There‌‌will‌‌be‌‌no‌‌costs‌‌beyond‌‌the‌‌normal‌‌labor‌‌costs‌‌for‌‌staff.‌  ‌
 ‌
15.‌‌Explain‌‌the‌‌reasons‌‌for‌‌any‌‌program‌‌changes‌‌or‌‌adjustments‌‌reported‌‌on‌‌the‌‌burden‌  ‌
worksheet.‌   ‌ ‌
This‌‌is‌‌a‌‌new‌‌program.‌   ‌ ‌
 ‌
16.‌‌For‌‌collections‌‌of‌‌information‌‌whose‌‌results‌‌will‌‌be‌‌published,‌‌outline‌‌plans‌‌for‌‌tabulation‌  ‌
and‌‌publication.‌‌Address‌‌any‌‌complex‌‌analytical‌‌techniques‌‌that‌‌will‌‌be‌‌used.‌‌Provide‌‌the‌  ‌
time‌‌schedule‌‌for‌‌the‌‌entire‌‌project,‌‌including‌‌beginning‌‌and‌‌ending‌‌dates‌‌of‌‌the‌‌collection‌‌of‌  ‌
information,‌‌completion‌‌of‌‌report,‌‌publication‌‌dates,‌‌and‌‌other‌‌actions.‌   ‌ ‌
Results‌‌will‌‌not‌‌be‌‌published.‌‌
   ‌
 ‌
17.‌‌If‌‌you‌‌are‌‌seeking‌‌approval‌‌to‌‌not‌‌display‌‌the‌‌expiration‌‌date‌‌for‌‌OMB‌‌approval‌‌of‌‌the‌  ‌
information‌‌collection,‌‌explain‌‌the‌‌reasons‌‌that‌‌display‌‌would‌‌be‌‌inappropriate.‌   ‌ ‌
We‌‌are‌‌not‌‌seeking‌‌approval‌‌to‌‌not‌‌display‌‌the‌‌expiration‌‌date‌‌for‌‌OMB‌‌approval‌‌of‌‌the‌‌information‌‌

collection.‌  ‌
 ‌
18.‌‌Explain‌‌each‌‌exception‌‌to‌‌the‌‌topics‌‌of‌‌the‌‌certification‌‌statement‌‌identified‌‌in‌  ‌
Certification‌‌for‌‌Paperwork‌‌Reduction‌‌Act‌‌Submissions.‌   ‌ ‌
There‌‌are‌‌no‌‌requested‌‌exceptions‌‌to‌‌the‌‌topics‌‌of‌‌the‌‌certification‌‌statement‌‌identified‌‌in‌‌the‌‌

Certification‌‌for‌‌Paperwork‌‌Reduction‌‌Act‌‌Submissions‌‌section‌‌of‌‌OMB‌‌form‌‌83-I.‌   ‌ ‌
 ‌
PART‌‌B.‌‌COLLECTIONS‌‌OF‌‌INFORMATION‌‌EMPLOYING‌‌STATISTICAL‌  ‌
METHODS‌   ‌ ‌
The‌‌collection‌‌does‌‌not‌‌employ‌‌statistical‌‌methods.‌ 

 ‌ ‌