View RCF  - OIRA Conclusion

202205-1093-001CF 202108-1093-001CF
Active 05/31/2025
DOI/OS
3206-0277 202202-3206-002
DOI Certification of Vaccination Attestation Common Form (Contractors and Visitors)
RCF Recertification
 Approved   05/24/2022
Retrieve Notice of Action (NOA) 05/24/2022
DOI will use this common form to promote the safety of our Federal buildings, and Federal workforce consistent with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force and guidance from the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration. Specifically, this form will be used by DOI staff charged with implementing and enforcing workplace safety protocols when requesting attestation of vaccination status from contractors and visitors. The information collected on this form is not being collected, maintained, or retained by DOI. If that changes, an appropriate Privacy Act statement or other assurance of confidentiality, as appropriate, will be provided and request for use revised.
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
 
Jeffrey Parrillo 202 208-7072 [email protected]

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
Form and Instruction CV2 Certification of Vaccination Common Form

  Total Approved 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 30,000 30,000 0 0 0 0
Annual Time Burden (Hours) 900 1,000 0 0 -100 0
Annual Cost Burden (Dollars) 27,006 24,360 0 0 2,646 0

Yes
Miscellaneous Actions
No