Certification of Vaccination

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Certification of Vaccination	Form and Instruction	Unchanged	Missing upstream
EO 13991.pdf	Supplementary Document	Uploaded 2022-02-09	Repair queued
3170-0075 supporting statement.docx	Supporting Statement A	Uploaded 2022-02-09	Repair queued
3170-0075 30-day FRN (published).pdf	Supplementary Document	Uploaded 2022-02-07	Repair queued
3170-0075 60-day FRN (published).pdf	Supplementary Document	Uploaded 2022-01-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
249212	Certification of Vaccination	Form and Instruction	Unchanged

ICR Details

OMB Control No: 3170-0075	ICR Reference No: 202201-3170-001
Status: Received in OIRA	Previous ICR Reference No: 202109-3170-002
Agency/Subagency: CFPB	Agency Tracking No:
Title: Certification of Vaccination
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/09/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2022
Responses	1,500	1,500
Time Burden (Hours)	125	125
Cost Burden (Dollars)	0	0

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Abstract: The Consumer Financial Protection Bureau (CFPB or the Bureau) is establishing safety protocols for both fully vaccinated and unvaccinated people. This information collection (e.g. the certification form) will ascertain individuals’ vaccination status in order for the Bureau to comply with Executive Order 13991 titled Protecting the Federal Workforce and Requiring Mask-Wearing. In compliance with guidance from the Centers for Disease Control and Prevention (CDC) and the Safer Federal Workforce Task Force, the Bureau is collecting this information from fully vaccinated individuals so that they can comply with Bureau safety guidelines. The Bureau is also collecting this information from partially or unvaccinated individuals so that that other measures can be implemented to enforce Bureau safety guidelines (e.g. wearing masks, physical/social distancing, regular testing, adherence to applicable travel requirements). The Bureau requests these data to promote the safety of Federal buildings, the Federal workforce, and others on site at agency facilities consistent with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force and guidance from the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration. Specifically, Bureau staff will use these data for implementing and enforcing workplace safety protocols.

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Authorizing Statute(s): None

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
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 63344	11/16/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 6851	02/07/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Certification of Vaccination	N/A	Certification of Vaccination

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ICR Summary of Burden

table that charts list 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	1,500	1,500	0	0	0	0
Annual Time Burden (Hours)	125	125	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

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? Yes

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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: 02/09/2022

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