Regulatory Collection Filing

Vaccine Status Form for Contractors & Visitors

RCF 202108-3015-001CF · Host ICR 202108-3206-001 · OMB 3206-0277

RCF Summary

Host OMB Control No.	3206-0277
Host ICR Reference No.	202108-3206-001
Agency/Subagency	DFC
Status	Active
Type of RCF	RCF New
OIRA Conclusion Action	Approved without change
Date Received in OIRA	2021-08-13
Conclusion Date	2021-08-13
Agency Tracking No.	DFC-019
Related Links	OMB 3206-0277 · ICR 202108-3206-001 · Retrieve Notice of Action (NOA)

RCF Details

View RCF - OIRA Conclusion

RCF ID: 202108-3015-001CF	Previous RCF ID:
Status: Active	Expiration Date: 02/28/2022
Agency/Subagency: DFC	Agency Tracking No: DFC-019
Host OMB Control No: 3206-0277	Host ICR Reference No: 202108-3206-001

Title: Vaccine Status Form for Contractors & Visitors

Type of RCF: RCF New
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/13/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/13/2021
Terms of Clearance:

Description of Agency Usage: The form will be used by Visitors (i.e. General Public or Federal employees at other agencies) and DFC contractors. Contractors and Visitors will have to retain (once completed) to show as requested for entry.

Authorizing Statute(s): None

Annual Cost to Federal Government:
Agency Contact: Joanna Reynolds 202 357-3979 [email protected]

Common Form Information Collections (IC) in this RCF:

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Certification of Vaccination Common Form		200	7	162	Form	3206-0277	Certification of Vaccination Common Form

RCF Summary of Burden:

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	200	200
Annual Time Burden (Hours)	7	7
Annual Cost Burden (Dollars)	162	162

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: Due to Government-wide COVID Safety protocol this new attestation form for Vaccination Status was created, formalizing an additional burden.