View RCF  - Agency Submission

Received in OIRA 02/28/2022
3206-0277 202108-3206-003
Certification of Vaccination Common Form
The President's Safer Federal Workforce Taskforce directed agencies to ask about the COVID-19 vaccination status of onsite contractors and visitors to federal buildings. The Federal Trade Commission (FTC) will use this common form to prevent the spread of COVID-19 and to protect the health and safety of all Federal employees, onsite contractors, visitors to Federal buildings or Federally controlled indoor workspaces, and other individuals interacting with the Federal workforce. The FTC specifically plans to sponsor disclosures on the form by contractors and visitors to FTC facilities. These individuals must show the completed form before being allowed access to the office space and upon request while in agency-controlled space. The information collected on this form is not being collected, maintained, or retained by the FTC.
Richard Gold 202 326-3355 [email protected]

IC Title Status Responses Hours Dollars Document Type Form No. Form Name

  Total Request 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 2,320 0 2,320 0 0 0
Annual Time Burden (Hours) 77 0 77 0 0 0
Annual Cost Burden (Dollars) 1,884 0 1,884 0 0 0