Individuals or Households

COVID-19 Vaccine Attestation Form for Non-paid Employees

Documents and Forms

Document Name Document Type
Form FCC Form 5644 Individuals or Households Form and Instruction
FCC Form 5644 VACCINATION AND ATTESTATION DOCUMENTATION FORM Vaccination Status Survey Form - FINAL with Booster request redacted.pdf Form and Instruction
FCC Form 5644 VACCINATION AND ATTESTATION DOCUMENTATION FORM Vaccination Status Survey Home - Vaccination Status Survey.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Individuals or Households	Agency IC Tracking Number:	OMD-IO

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection 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 Status Survey Home - Vaccination Status Survey.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: 140	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	140	128	12
Annual IC Time Burden (Hours)	35	32	3
Annual IC Cost Burden (Dollars)	0	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.