COVID-19 Vaccine Attestation Form for Non-paid Employees

Forms and Documents

Document Name	Status
Form FCC Form 5644 Federal Government Form and Instruction	New
Form FCC Form 5644 Individuals or Households Form and Instruction	New
Emergency PRA Approval Cover Letter for COVID Form for nonpaid employees v1 (003) signed.pdf Supplementary Document	2021-11-19
Emergency PRA Supporting Statement for COVID attestation form for nonpaid employees v2.docx Supporting Statement A	2021-11-12

IC Document Collections

IC ID	Document Title	Status
250337	Federal Government Form and Instruction	New
250336	Individuals or Households Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202111-3060-004
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: FCC	Agency Tracking No: OMD-FO
Title: COVID-19 Vaccine Attestation Form for Non-paid Employees
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: 11/19/2021
Date Submitted to OIRA: 11/19/2021

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	25	0
Time Burden (Hours)	6	0
Cost Burden (Dollars)	0	0

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Abstract: Pursuant to Executive Order 14043, Federal employees must be fully vaccinated against COVID-19 by November 22, 2021. To ensure compliance with this mandate, the FCC is requiring employees to complete and submit an electronic form attesting to their current vaccination status. For some special categories of individuals who perform (or will perform) work for the agency but are not considered employees, however, the FCC is required to obtain OMB approval prior to collecting such information. These include incoming employees, unpaid interns, unpaid legal fellows, individuals performing work for the FCC pursuant to an Intergovernmental Personnel Agreement, participants in advisory committees, and possibly other similar classes of individuals who are not on the FCC payroll but are performing work for the agency.

Emergency Justfication: The Federal Communications Commission (Commission or FCC) requests Office of Management and Budget (OMB) approval to submit the information collection described herein under the “emergency processing” provisions of the Paperwork Reduction Act (PRA) of 1995, 5 CFR 1320.13. The Commission is requesting clearance for a new information collection entitled [3060-XXXX], Vaccination Attestation and Documentation, FCC Form 5644. For the reasons explained below, We respectfully request OMB approval for this new information collection at the earliest possible time. The information collection requirements to be reported under this new collection are the result of requirements imposed by an Executive Order issued by President Biden regarding mandatory COVID-19 vaccination among Federal employees. On September 9, 2021, President Biden issued Executive Order 14043 to protect the health and safety of the Federal workforce and to promote the efficiency of the civil service. Pursuant to the Executive Order and implementing guidance, the Federal Communications Commission (FCC) informed its workforce that, other than in limited circumstances where a reasonable accommodation is legally required, all employees need to be fully vaccinated against COVID-19 by November 22, 2021, regardless of where they are working. To ensure compliance with this mandate, the FCC is requiring employees to complete and submit an electronic form attesting to their current vaccination status. For some special categories of individuals who perform (or will perform) work for the agency but are not considered employees, however, the FCC is required to obtain OMB approval prior to collecting such information. These include incoming employees, unpaid interns, unpaid legal fellows, individuals performing work for the FCC pursuant to an Intergovernmental Personnel Agreement, participants in advisory committees, and possibly other similar classes of individuals who are not on the FCC payroll but are performing work for the agency.

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Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Federal Government	FCC Form 5644	VACCINATION AND ATTESTATION DOCUMENTATION FORM
Individuals or Households	FCC Form 5644	VACCINATION AND ATTESTATION DOCUMENTATION FORM

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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	25	0	0	25	0	0
Annual Time Burden (Hours)	6	0	0	6	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: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection resulting in a program change/increase of 25 respondents, 25 responses, and 6 total estimated burden hours.

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Annual Cost to Federal Government:

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? No

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Common Form ICR:  No

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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: 11/19/2021

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