Information Collection

Individuals or Households

IC 250336 under ICR 202205-3060-022 · OMB 3060-1297.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

OMD-IO

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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
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 %

table that charts list of burden
	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

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.