Regulatory Collection Filing

USDA Certification of Vaccination Attestation Common Form (Contractors and Visitors)

RCF 202205-0503-001CF · 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	USDA/AgSEC
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 202108-0503-002CF · Retrieve Notice of Action (NOA)

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Title: USDA Certification of Vaccination Attestation Common Form (Contractors and Visitors)

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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:

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Description of Agency Usage: The Department will use this form to prevent the spread of COVID-19, and to protect the health and safety of all persons in USDA buildings. The form will be used by contractors and visitors to document their vaccination status. They will retain the completed form to show as requested for entry.

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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:
Agency Contact: Ruth Brown 202 720-8958 [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		30,000	900	27,006	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		30,000	900	27,006	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	30,000	30,000	0
Annual Time Burden (Hours)	900	900	0
Annual Cost Burden (Dollars)	27,006	24,360	2,646

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: