View RCF - OIRA Conclusion

Title: Certification of Vaccination

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 Tennessee Valley Authority 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 Tennessee Valley Authority staff charged with implementing and enforcing workplace safety protocols when requesting attestation of vaccination status from onsite contractors and visitors. The information collected on this form is not being collected, maintained, or retained by the Tennessee Valley Authority. If that changes, a Privacy Act statement or other assurance of confidentiality, as appropriate, will be provided and the request for use will be revised.

Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing

Annual Cost to Federal Government: $0
Agency Contact: Chris Marsalis 865 632-2467 [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		10,000	300	9,002	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		10,000	300	9,002	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	10,000	10,000	0
Annual Time Burden (Hours)	300	300	0
Annual Cost Burden (Dollars)	9,002	8,120	882

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:

202205-3316-001CF