Regulatory Collection Filing

Vaccine Status Form for Contractors & Visitors

RCF 202205-3015-001CF · Host ICR 202202-3206-002 · OMB 3206-0277

RCF Summary

Host OMB Control No.	3206-0277
Host ICR Reference No.	202202-3206-002
Agency/Subagency	DFC
Status	Active
Type of RCF	RCF Recertification
OIRA Conclusion Action	Approved
Date Received in OIRA	2022-05-24
Conclusion Date	2022-05-24
Agency Tracking No.	DFC-019
Related Links	OMB 3206-0277 · ICR 202202-3206-002 · Previous RCF 202108-3015-002CF · Retrieve Notice of Action (NOA)

RCF Details

View RCF - OIRA Conclusion

Title: Vaccine Status Form for Contractors & Visitors

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:

Description of Agency Usage: The form will be used by Visitors (i.e. General Public or Federal employees at other agencies) and DFC contractors. Contractors and Visitors will have to retain (once completed) to show as requested for entry.

Authorizing Statute(s): None

Annual Cost to Federal Government:
Agency Contact: Joanna Reynolds 202 357-3979 [email protected]

Common Form Information Collections (IC) in this RCF:

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Certification of Vaccination Common Form		200	6	180	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		200	6	180	Form and Instruction	CV2	Certification of Vaccination Common Form

RCF Summary of Burden:

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	200	200	0
Annual Time Burden (Hours)	6	6	0
Annual Cost Burden (Dollars)	180	162	18

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: