Regulatory Collection Filing

Certification of Vaccination Form

RCF 202205-1880-001CF · 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	ED/OM
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 202109-1880-001CF · Retrieve Notice of Action (NOA)

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Title: Certification of Vaccination Form

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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: ED will use this form to collect vaccination status from visitors and contractors to ED headquarters, local and regional office buildings where services are provided.

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Authorizing Statute(s): None

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Annual Cost to Federal Government:
Agency Contact: Stephanie Valentine 202 401-0526 [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		5,829	175	5,247	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		5,829	175	5,247	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	5,829	5,829	0
Annual Time Burden (Hours)	175	194	-19
Annual Cost Burden (Dollars)	5,247	4,733	514

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: