Certification of COVID-19 Vaccination Status

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CV2 Certification of Vaccination Common Form	Form and Instruction	Modified	Available
Form OPM 5062 Certification Vaccination Employee	Form and Instruction	Modified	Available
Form OPM 5062 Certification of Vaccination Common Form	Form and Instruction	Modified	Repair queued
Supporting Statement Vaccination Attestation Common Form_3206-0277.2 9 22 draftCCC.docx	Supporting Statement A	Uploaded 2022-02-17	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
248751	Certification of Vaccination Common Form	Form and Instruction	Modified	Certification of Vaccination Common Form
248751	Certification of Vaccination Common Form	Form and Instruction	Modified	Certification Vaccination Employee
248751	Certification of Vaccination Common Form	Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0277	ICR Reference No: 202202-3206-002
Status: Historical Active	Previous ICR Reference No: 202108-3206-003
Agency/Subagency: OPM	Agency Tracking No:
Title: Certification of COVID-19 Vaccination Status
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/24/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/17/2022
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2025	36 Months From Approved	05/31/2022
Responses	3,952	0	1,500
Time Burden (Hours)	132	0	50
Cost Burden (Dollars)	3,558	0	1,218

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Abstract: Pursuant to Office of Management and Budget (OMB) procedures established at 5 C.F.R. Part 1320, Controlling Paperwork Burdens on the Public, I request that the proposed information collection, the Certification of Vaccination Common Form, OMB Control No. 3206-0277, be processed in accordance with 5 C.F.R. §1320.13, Government agencies have an urgent need to request attestation of vaccination status from individuals entering Federal buildings and workspaces.

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Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
  

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 223	11/23/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 33	02/17/2022
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 Common Form	OPM 5062, CV2	Certification Vaccination Employee ,   Certification of Vaccination Common Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	3,952	1,500	0	2,452	0	0
Annual Time Burden (Hours)	132	50	0	82	0	0
Annual Cost Burden (Dollars)	3,558	1,218	0	2,340	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: Return to workplace from max telework will increase public traffic.

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Annual Cost to Federal Government: $29,703

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:  Yes

OIRA authorizes any Agency to begin using a Common Form associated with this ICR automatically after 5 calendar days from the date the agency's RCF including the common form was received in OIRA.

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

table that charts list of RCF

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title
TVA	202205-3316-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
FTC	202205-3084-001CF	Certification of Vaccination Common Form	Historical Active	Certification of Vaccination Common Form
DHS/TSA	202205-1652-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
EPA/OMS	202205-2030-001CF	Certification of Vaccination Common Form	Historical Active	Certification of Vaccination Common Form
DNFSB	202205-3155-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
CFTC	202206-3038-001CF	Certification of Vaccination Form	Historical Active	Certification of Vaccination Common Form
CNCS	202205-3045-001CF	Vaccination Attestation Form for Contractors	Historical Active	Certification of Vaccination Common Form
TREAS/DO	202205-1505-001CF	Certification of Vaccination Common Form - Treasury Department	Historical Active	Certification of Vaccination Common Form
HHS/ACF	202205-0970-001CF	Certification of Vaccination Form	Historical Active	Certification of Vaccination Common Form
NARA	202205-3095-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
PEACE	202205-0420-001CF	Certification of Vaccination for Visitors and On-Site Contractors	Historical Active	Certification of Vaccination Common Form
NRC	202205-3150-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
HHS/FDA	202411-0910-001CF	Certification of Vaccination Form	Historical Active	Certification of Vaccination Common Form
FHFA	202205-2590-001CF	FHFA Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
DOC/CENSUS	202205-0607-001CF	Census Bureau Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
DOC/NIST	202205-0693-001CF	NIST Certification of Vaccination Attestation Common Form (Contractors and Visitors)	Historical Active	Certification of Vaccination Common Form
DOC/OS	202205-0690-001CF	DOC/OS Certification of Vaccination Attestation Common Form (Contractors and Visitors)	Historical Active	Certification of Vaccination Common Form
DOC/NTIA	202205-0660-002CF	NTIA Certification of Vaccination (Contractors and Visitors)	Historical Active	Certification of Vaccination Common Form
SEC	202205-3235-001CF	Certification of Vaccination Common Form	Historical Active	Certification of Vaccination Common Form
IMLS	202205-3137-001CF	Certification of Vaccination Common Form	Historical Active	Certification of Vaccination Common Form
HHS/ACF	202206-0970-001CF	Certification of Vaccination Form	Historical Active	Certification of Vaccination Common Form
OGE	202205-3209-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
DOC/NOAA	202205-0648-001CF	NOAA Certification of Vaccination Attestation Common Form (Contractors and Visitors)	Historical Active	Certification of Vaccination Common Form
FMCS	202205-3076-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
CPSC	202205-3041-001CF	CPSC Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
DFC	202205-3015-001CF	Vaccine Status Form for Contractors & Visitors	Historical Active	Certification of Vaccination Common Form
FDIC	202205-3064-001CF	Certification Vaccination Common Form - Visitors and Contractors	Historical Active	Certification of Vaccination Common Form
NSF	202205-3145-001CF	National Science Foundation Certification of Vaccination - Contractors and Visitors	Historical Active	Certification of Vaccination Common Form
NIGC	202205-3141-001CF	Certification of Vaccine Form (NIGC)	Historical Active	Certification of Vaccination Common Form
AID	202205-0412-001CF	Certification of Vaccination Form	Historical Active	Certification of Vaccination Common Form
MSPB	202205-3124-001CF	Certification of COVID-19 Vaccination Status	Historical Active	Certification of Vaccination Common Form
USDA/AgSEC	202205-0503-001CF	USDA Certification of Vaccination Attestation Common Form (Contractors and Visitors)	Historical Active	Certification of Vaccination Common Form
DOL/ETA	202205-1205-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
ED/OM	202205-1880-001CF	Certification of Vaccination Form	Historical Active	Certification of Vaccination Common Form
DOL/DM	202205-1225-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
SSS	202205-3240-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
DOI/OS	202205-1093-001CF	DOI Certification of Vaccination Attestation Common Form (Contractors and Visitors)	Historical Active	Certification of Vaccination Common Form
DOC/NTIA	202205-0660-001CF	FirstNet Certification of Vaccination (Contractors and Visitors)	Historical Active	Certification of Vaccination Common Form
DOC/PTO	202205-0651-001CF	USPTO: Certification of Vaccination Common Form	Historical Active	Certification of Vaccination Common Form
FERC	202205-1902-001CF	Certification of Vaccination Status	Historical Active	Certification of Vaccination Common Form
FCC	202205-3060-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form
TREAS/OCC	202205-1557-001CF	Certification of Vaccination	Historical Active	Certification of Vaccination Common Form

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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: 02/17/2022

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