Regulatory Collection Filing

Certification of Vaccination Form

RCF 202206-0970-001CF · 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	HHS/ACF
Status	Active
Type of RCF	RCF No material or nonsubstantive change to a currently approved collection
OIRA Conclusion Action	Approved without change
Date Received in OIRA	2022-06-07
Conclusion Date	2022-06-07
Agency Tracking No.	ACF
Related Links	OMB 3206-0277 · ICR 202202-3206-002 · Previous RCF 202205-0970-001CF · Retrieve Notice of Action (NOA)

RCF Details

View RCF - OIRA Conclusion

Title: Certification of Vaccination Form

Type of RCF: RCF No material or nonsubstantive change to a currently approved collection
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/07/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/07/2022
Terms of Clearance:

Description of Agency Usage: ACF will use this form to collect vaccination status from visitors and contractors to ACF headquarters, local and regional office buildings, and other spaces where services are provided or events take place.

Authorizing Statute(s): None

Annual Cost to Federal Government:
Agency Contact: Molly Buck 202 205-4724 [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		8,000	267	7,202	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		8,000	267	7,202	Form and Instruction	CV2	Certification of Vaccination Common Form

RCF Summary of Burden:

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	8,000	1,000	7,000
Annual Time Burden (Hours)	267	33	234
Annual Cost Burden (Dollars)	7,202	900	6,302

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: ACF inadvertently did not include an estimate for all expected entrants to buildings/events.