Regulatory Collection Filing

Certification of Vaccination Form

RCF 202205-0412-001CF · Host ICR 202202-3206-002 · OMB 3206-0277

RCF Summary

Request for correction metadata
Host OMB Control No.	3206-0277
Host ICR Reference No.	202202-3206-002
Agency/Subagency	AID
Status	Active
Type of RCF	RCF Recertification
OIRA Conclusion Action	Approved
Date Received in OIRA	2022-05-24
Conclusion Date	2022-05-24
Related Links	OMB 3206-0277 · ICR 202202-3206-002 · Previous RCF 202108-0412-003CF · Retrieve Notice of Action (NOA)

Reginfo record details
Title: Certification of Vaccination Form

Reginfo record details
Type of RCF: RCF Recertification
OIRA Conclusion Action: Approved	Conclusion Date: 05/24/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/24/2022
Terms of Clearance:

Reginfo record details
Description of Agency Usage: The purpose of this collection is to prevent the spread of COVID-19, to protect the health and safety of Federal employees, onsite contractors, and visitors and individuals interacting with the Federal workforce. The form will be used for the attestation of vaccine status by Federal employees, contractors, and visitors.

Reginfo record details
Authorizing Statute(s): None

Reginfo record details
Annual Cost to Federal Government:
Agency Contact: Taniesha Tolbert 202 712-1217 [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
Certification of Vaccination Common Form		5,384	162	4,847	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		5,384	162	4,847	Form and Instruction	CV2	Certification of Vaccination Common Form

RCF Summary of Burden:

table that charts list of burden
	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	5,384	5,384	0
Annual Time Burden (Hours)	162	179	-17
Annual Cost Burden (Dollars)	4,847	4,372	475

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: