Regulatory Collection Filing

Certification of Vaccination Common Form - Treasury Department

RCF 202110-1505-001CF · Host ICR 202108-3206-003 · OMB 3206-0277

RCF Summary

Request for correction metadata
Host OMB Control No.	3206-0277
Host ICR Reference No.	202108-3206-003
Agency/Subagency	TREAS/DO
Status	Received in OIRA
Type of RCF	RCF New
OIRA Conclusion Action	View RCF focusMethod = function getFocus() { document.getElementById("main").focus(); } .skip-main { border-color: transparent;
Date Received in OIRA	1969-12-31
Conclusion Date	1969-12-31
Related Links	OMB 3206-0277 · ICR 202108-3206-003

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Title: Certification of Vaccination Common Form - Treasury Department

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Type of RCF: RCF New

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Description of Agency Usage: The Department of the Treasury (including its Bureaus) will use this common form to gather vaccination status from onsite contractors and visitors at all Treasury facilities. This is in accordance with with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force and guidance from the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration.

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

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Annual Cost to Federal Government: $28,033
Agency Contact: Spencer Clark 202 566-0729 [email protected]

Common Form Information Collections (IC) in this RCF:

table that charts list of ICs
IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name

RCF Summary of Burden:

table that charts list of burden
	Total Request	Change Due to Agency Discretion
Annual Number of Responses	50,000	50,000
Annual Time Burden (Hours)	1,667	1,667
Annual Cost Burden (Dollars)	40,600	40,600

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: This is a new form, required for compliance with EO 13991.