Regulatory Collection Filing

Certification of Vaccination Common Form

RCF 202110-3235-001CF · 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	SEC
Status	Active
Type of RCF	RCF New
OIRA Conclusion Action	Approved without change
Date Received in OIRA	2021-10-12
Conclusion Date	2021-10-12
Agency Tracking No.	270-826
Related Links	OMB 3206-0277 · ICR 202108-3206-003 · Retrieve Notice of Action (NOA)

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Title: Certification of Vaccination Common Form

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Type of RCF: RCF New
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/12/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/12/2021
Terms of Clearance:

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Description of Agency Usage: SEC will require employees to complete and submit this form. SEC will require contractors and visitors to complete this form and produce it upon request.

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Authorizing Statute(s): None

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Annual Cost to Federal Government:
Agency Contact: John Pezzullo 202 551-8118 [email protected]

Common Form Information Collections (IC) in this RCF:

table that charts list of ICs
IC Title	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Certification of Vaccination Common Form	3,737	125	3,034	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:

table that charts list of burden
	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	3,737	3,737
Annual Time Burden (Hours)	125	125
Annual Cost Burden (Dollars)	3,034	3,034

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: The burden increased in alignment with the anticipated number of respondents.