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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Appian Screen Shots.docx	Other-Screenshots
Appian Screen Shots.docx	Other-Screenshots

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:

table that charts list of 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 %

table that charts list of burden
	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

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.