View RCF
- OIRA Conclusion
RCF ID: 202108-3124-002CFPrevious RCF ID: 202108-3124-001CF
Status:
Active
Expiration Date: 02/28/2022
Agency/Subagency: MSPBAgency Tracking No:
Host OMB Control No: 3206-0277Host ICR Reference No: 202108-3206-003
Title: Certification of COVID-19 Vaccination Status
Type of RCF: RCF Recertification
OIRA Conclusion Action: ApprovedConclusion Date:
08/26/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/26/2021
Terms of Clearance:
Description of Agency Usage:
Given that the health and safety of employees, contractors, and visitors at the U.S. Merit Systems Protection Board (MSPB) is our highest priority, MSPB is using this form to ascertain the COVID-19 vaccination status of its contractors and visitors to ensure that the appropriate safety protocols are followed depending on vaccination status and Federal health and safety guidelines.
Authorizing Statute(s):
None
Annual Cost to Federal Government:
Agency Contact:
Fon Muttamara 202 254-4772 [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
1,500
45
1,218
Form
3206-0277
Certification of Vaccination Common Form
Form and Instruction
OPM 5062
Certification Vaccination Employee
Form and Instruction
3206-0277
Certification Vaccination PRA
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
1,500
1,500
0
0
0
0
Annual Time Burden (Hours)
45
50
0
0
-5
0
Annual Cost Burden (Dollars)
1,218
1,218
0
0
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: