Regulatory Collection Filing

Vaccination Attestation Form for Contractors

RCF 202205-3045-001CF · 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	CNCS
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 202109-3045-001CF · Retrieve Notice of Action (NOA)

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Title: Vaccination Attestation Form for Contractors

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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: AmeriCorps will require employees to complete and submit this form. AmeriCorps will require contractors and visitors to complete this form and produce it upon request.

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Authorizing Statute(s): None

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Annual Cost to Federal Government:
Agency Contact: Amy Borgstrom 202 606-6930 [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		800	24	720	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		800	24	720	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	800	800	0
Annual Time Burden (Hours)	24	27	-3
Annual Cost Burden (Dollars)	720	650	70

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: