Regulatory Collection Filing

Certification of Vaccination

RCF 202108-3155-002CF · Host ICR 202108-3206-003 · OMB 3206-0277

RCF Summary

Host OMB Control No.	3206-0277
Host ICR Reference No.	202108-3206-003
Agency/Subagency	DNFSB
Status	Active
Type of RCF	RCF Recertification
OIRA Conclusion Action	Approved
Date Received in OIRA	2021-08-26
Conclusion Date	2021-08-26
Agency Tracking No.	202108-3155-001CF
Related Links	OMB 3206-0277 · ICR 202108-3206-003 · Previous RCF 202108-3155-001CF · Retrieve Notice of Action (NOA)

RCF Details

View RCF - OIRA Conclusion

Title: Certification of Vaccination

Type of RCF: RCF Recertification
OIRA Conclusion Action: Approved	Conclusion Date: 08/26/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/26/2021
Terms of Clearance:

Description of Agency Usage: The form will be used by DNFSB contractors and visitors to document their vaccination status. They will retain the completed form to show as requested for entry.

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

Annual Cost to Federal Government: $100
Agency Contact: James Biggins 202 694-7014 [email protected]

Common Form Information Collections (IC) in this RCF:

IC Title	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Certification of Vaccination Common Form	100	3	81	Form	3206-0277	Certification of Vaccination Common Form
				Form and Instruction	OPM 5062	Certification Vaccination Employee
				Form and Instruction	3206-0277	Certification Vaccination PRA

RCF Summary of Burden:

	Total Approved	Previously Approved
Annual Number of Responses	100	100
Annual Time Burden (Hours)	3	3
Annual Cost Burden (Dollars)	81	81

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: