Regulatory Collection Filing

Certification of Verification Form

RCF 202202-1880-002CF · 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	ED/OM
Status	Active
Type of RCF	RCF New
OIRA Conclusion Action	Approved without change
Date Received in OIRA	2022-02-01
Conclusion Date	2022-02-01
Related Links	OMB 3206-0277 · ICR 202108-3206-003 · Retrieve Notice of Action (NOA)

RCF Details

View RCF - OIRA Conclusion

RCF ID: 202202-1880-002CF	Previous RCF ID:
Status: Active	Expiration Date: 02/28/2022
Agency/Subagency: ED/OM	Agency Tracking No:
Host OMB Control No: 3206-0277	Host ICR Reference No: 202108-3206-003

Title: Certification of Verification Form

Type of RCF: RCF New
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/01/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/01/2022
Terms of Clearance:

Description of Agency Usage: ED will use this form to collect vaccination status from visitors and contractors to ED headquarters, local and regional office buildings where services are provided.

Authorizing Statute(s): None

Annual Cost to Federal Government:
Agency Contact: Stephanie Valentine 202 401-0526 [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	5,829	194	4,733	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	Change Due to Agency Discretion
Annual Number of Responses	5,829	5,829
Annual Time Burden (Hours)	194	194
Annual Cost Burden (Dollars)	4,733	4,733

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 an extension of a previously approved request. This results in an increase in burden and responses of 194 hours and 5,829 responses.