Information Collection

Federal Government

IC 250337 under ICR 202111-3060-004 · OMB 3060-1297.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-1297 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FCC Form 5644 Federal Government	Form and Instruction
FCC Form 5644 VACCINATION AND ATTESTATION DOCUMENTATION FORM Vaccination Attestation and Documentation Form v1.pdf	Form and Instruction
FCC Form 5644 VACCINATION AND ATTESTATION DOCUMENTATION FORM Vaccination Attestation and Documentation Form v1.pdf	Form and Instruction

IC Title:

Federal Government

Agency IC Tracking Number:

OMD-IO

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	FCC Form 5644	VACCINATION AND ATTESTATION DOCUMENTATION FORM	Vaccination Attestation and Documentation Form v1.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records

Title: FCC/OMD-33, Ensuring Workplace Health and Safety in Response to a Public Health Emergency

FR Citation: 86 FR 32674

Number of Respondents: 13

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

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	13	13
Annual IC Time Burden (Hours)	3	3
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.