Information Collection

Vaccination Attestation Form

IC 250776 under ICR 202112-1557-001 · OMB 1557-0355.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1557-0355 can be found here:

Documents and Forms

Document Name Document Type
Appian Screen Shots.docx Other-Screenshots
Appian Screen Shots.docx Other-Screenshots

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Vaccination Attestation Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screenshots			Appian Screen Shots.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	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	250	250
Annual IC Time Burden (Hours)	63	63
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.