Regulatory Collection Filing

Certification of Vaccination Form

RCF 202411-0910-001CF · 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	HHS/FDA
Status	Received in OIRA
Type of RCF	RCF New
OIRA Conclusion Action	(function(){var g=function(e,h,f,g){ this.get=function(a){for(var a=a+"=",c=document.cookie.split(";"),b=0,e=c.length;b=e/100?0:
Date Received in OIRA	1969-12-31
Conclusion Date	1969-12-31
Related Links	OMB 3206-0277 · ICR 202202-3206-002

Reginfo record details
Title: Certification of Vaccination Form

Reginfo record details
Type of RCF: RCF New

Reginfo record details
Description of Agency Usage: FDA will use this form to collect vaccination and surveillance status from visitors (and people who will work with FDA) to FDA headquarters, local and regional office buildings, and other spaces where services are provided, or events take place.

Reginfo record details
Authorizing Statute(s): None

Reginfo record details
Annual Cost to Federal Government:
Agency Contact: Jonna Capezzuto 301 796-3794 [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

RCF Summary of Burden:

table that charts list of burden
	Total Request	Change Due to Agency Discretion
Annual Number of Responses	8,000	8,000
Annual Time Burden (Hours)	267	267
Annual Cost Burden (Dollars)	7,202	7,202

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: This is a new data collection for FDA.