202205-0970-001CF RCF OMB: 3206-0277
OMB.report
OMB 3206-0277
RCF 202205-0970-001CF
( RCF New )
Array
(
[refNbr] => 202205-0970-001CF
[obm] => 3206-0277
[icr] => 202202-3206-002
[status] => Received in OIRA
[agency] => HHS/ACF
[title] => Certification of Vaccination Form
[typeRCF] => RCF New
[oiraAction] => View RCF focusMethod = function getFocus() { document.getElementById("main").focus(); } .skip-main { border-color: transparent;
[oiraNOA] => View RCF focusMeth
[termsOfClearance] =>
[previousRCF] =>
[agencyTrackingNo] => ACF
[conclusionDate] => 1969-12-31
[dateReceived] => 1969-12-31
)
Document
View RCF
- Agency Submission
RCF ID: 202205-0970-001CFPrevious RCF ID:
Status:
Received in OIRA
Expiration Date: 05/31/2025
Agency/Subagency: HHS/ACFAgency Tracking No: ACF
Host OMB Control No: 3206-0277Host ICR Reference No: 202202-3206-002
Title: Certification of Vaccination Form
Description of Agency Usage:
ACF will use this form to collect vaccination status from visitors and contractors to ACF headquarters, local and regional office buildings, and other spaces where services are provided or events take place.
Authorizing Statute(s):
None
Annual Cost to Federal Government:
Agency Contact:
Molly Buck 202 205-4724 [email protected]
Common Form Information Collections (IC) in this RCF:
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Total Request
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
1,000
0
0
1,000
0
0
Annual Time Burden (Hours)
33
0
0
33
0
0
Annual Cost Burden (Dollars)
900
0
0
900
0
0
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 request for use of the Certification of Vaccination Common Form by ACF.