Regulatory Collection Filing

Certification of Vaccination Common Form - Treasury Department

RCF 202205-1505-001CF · 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	TREAS/DO
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 202110-1505-001CF · Retrieve Notice of Action (NOA)

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Title: Certification of Vaccination Common Form - Treasury Department

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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 of the Treasury (including its Bureaus) will use this common form to gather vaccination status from onsite contractors and visitors at all Treasury facilities. This is in accordance with 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.

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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: $28,033
Agency Contact: Spencer Clark 202 566-0729 [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		50,000	1,500	45,010	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		50,000	1,500	45,010	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	50,000	50,000	0
Annual Time Burden (Hours)	1,500	1,667	-167
Annual Cost Burden (Dollars)	45,010	40,600	4,410

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: