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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
3206-0277
ICR Reference No:
202108-3206-001
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
OPM
Agency Tracking No:
Title:
Certification of COVID-19 Vaccination Status
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
Yes
Type of Review Request:
Emergency
Approval Requested By:
08/06/2021
OIRA Conclusion Action:
Approved without change
Conclusion Date:
08/06/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/05/2021
Terms of Clearance:
This collection is approved for 6 months only. Should the agency want to continue to use this collection for longer than 6 months, OPM must publish a 60 and 30 day notice.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
02/28/2022
Responses
1,500
0
0
Time Burden (Hours)
50
0
0
Cost Burden (Dollars)
1,218
0
0
Abstract:
Emergency Justfication:
Authorizing Statute(s):
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Certification of Vaccination Common Form
3206-0277
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
1,500
0
0
1,500
0
0
Annual Time Burden (Hours)
50
0
0
50
0
0
Annual Cost Burden (Dollars)
1,218
0
0
1,218
0
0
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:
Not applicable.
Annual Cost to Federal Government:
$841
Does this IC contain surveys, censuses, or employ statistical methods?
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Kellie Riley 202 606-2308 kellie.riley@opm.gov
Common Form ICR:
Yes
OIRA authorizes any Agency to begin using a Common Form associated with this ICR automatically after 5 calendar days from the date the agency's RCF including the common form was received in OIRA.
Description/Changes for Common Form Usage:
Approved RCFs using this ICR
Agency/Sub Agency
RCF ID
RCF Title
RCF Status
IC Title
CPSC
202108-3041-001CF
CPSC Certification of Vaccination
Active
Certification of Vaccination Common Form
CFPB
202108-3170-001CF
Certification of Vaccination (CFPB)
Active
Certification of Vaccination Common Form
DOL/DM
202108-1225-001CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
IMLS
202108-3137-002CF
Certification of Vaccination Common Form
Active
Certification of Vaccination Common Form
FHFA
202108-2590-001CF
FHFA Certification of Vaccination
Active
Certification of Vaccination Common Form
DOC/OS
202108-0690-001CF
DOC/OS Certification of Vaccination Attestation Common Form (Contractors and Visitors)
Active
Certification of Vaccination Common Form
DFC
202108-3015-001CF
Vaccine Status Form for Contractors & Visitors
Active
Certification of Vaccination Common Form
NRC
202108-3150-001CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
DOC/CENSUS
202108-0607-001CF
Census Bureau Certification of Vaccination
Active
Certification of Vaccination Common Form
DOJ/DOJADM
202108-1103-001CF
Vaccine Attestation Form
Active
Certification of Vaccination Common Form
TVA
202108-3316-001CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
FDIC
202108-3064-001CF
Certification Vaccination Common Form - Visitors and Contractors
Active
Certification of Vaccination Common Form
SSS
202108-3240-001CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
MSPB
202108-3124-001CF
Certification of COVID-19 Vaccination Status
Active
Certification of Vaccination Common Form
DOC/NOAA
202108-0648-001CF
NOAA Certification of Vaccination Attestation Common Form (Contractors and Visitors)
Active
Certification of Vaccination Common Form
DOC/NTIA
202108-0660-001CF
NTIA Certification of Vaccination (Contractors and Visitors)
Active
Certification of Vaccination Common Form
DOC/NIST
202108-0693-001CF
NIST Certification of Vaccination Attestation Common Form (Contractors and Visitors)
Active
Certification of Vaccination Common Form
EPA/OMS
202108-2030-001CF
Certification of Vaccination Common Form
Active
Certification of Vaccination Common Form
NIGC
202108-3141-002CF
Certification of Vaccine Form (NIGC)
Active
Certification of Vaccination Common Form
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
08/05/2021
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