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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:
202108-3206-003
Status:
Historical Active
Previous ICR Reference No:
202108-3206-001
Agency/Subagency:
OPM
Agency Tracking No:
Title:
Certification of COVID-19 Vaccination Status
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
Yes
Type of Review Request:
Emergency
Approval Requested By:
08/06/2021
OIRA Conclusion Action:
Approved without change
Conclusion Date:
08/26/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/24/2021
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
02/28/2022
02/28/2022
02/28/2022
Responses
1,500
0
1,500
Time Burden (Hours)
50
0
50
Cost Burden (Dollars)
1,218
0
1,218
Abstract:
Pursuant to Office of Management and Budget (OMB) procedures established at 5 C.F.R. Part 1320, Controlling Paperwork Burdens on the Public, I request that the proposed information collection, the Certification of Vaccination Common Form, OMB Control No. 3206-NEW, be processed as an Emergency Clearance Request in accordance with 5 C.F.R. ยง1320.13, Emergency Processing.Government agencies have an urgent need to request attestation of vaccination status from individuals entering Federal buildings and workspaces. Applying regular Paperwork Reduction Act clearance procedures is likely to cause harm because of the threat of COVID-19 exposure and transmission.
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:
Not associated with rulemaking
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Certification of Vaccination Common Form
3206-0277, OPM 5062, 3206-0277
Certification of Vaccination Common Form
,
Certification Vaccination Employee
,
Certification Vaccination PRA
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
1,500
0
0
0
0
Annual Time Burden (Hours)
50
50
0
0
0
0
Annual Cost Burden (Dollars)
1,218
1,218
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
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?
No
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.
Yes
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.
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Yes
Agency Contact:
Charles Conyers 202 606-0125 charles.conyers@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:
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 and pending RCFs using this ICR
Approved RCFs using this ICR
Agency/Sub Agency
RCF ID
RCF Title
RCF Status
IC Title
CNCS
202109-3045-001CF
Vaccination Attestation Form for Contractors
Active
Certification of Vaccination Common Form
FHFA
202108-2590-002CF
FHFA Certification of Vaccination
Active
Certification of Vaccination Common Form
CFPB
202108-3170-002CF
Certification of Vaccination (CFPB)
Historical Active
Certification of Vaccination Common Form
DOC/NTIA
202108-0660-004CF
NTIA Certification of Vaccination (Contractors and Visitors)
Active
Certification of Vaccination Common Form
DNFSB
202108-3155-002CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
MSPB
202108-3124-002CF
Certification of COVID-19 Vaccination Status
Active
Certification of Vaccination Common Form
DOJ/DOJADM
202108-1103-002CF
Vaccine Attestation Form
Historical Active
Certification of Vaccination Common Form
SEC
202110-3235-001CF
Certification of Vaccination Common Form
Active
Certification of Vaccination Common Form
NSF
202108-3145-001CF
National Science Foundation Certification of Vaccination - Contractors and Visitors
Active
Certification of Vaccination Common Form
DOC/OS
202108-0690-002CF
DOC/OS Certification of Vaccination Attestation Common Form (Contractors and Visitors)
Active
Certification of Vaccination Common Form
EPA/OMS
202108-2030-002CF
Certification of Vaccination Common Form
Active
Certification of Vaccination Common Form
USDA/AgSEC
202108-0503-002CF
USDA Certification of Vaccination Attestation Common Form (Contractors and Visitors)
Active
Certification of Vaccination Common Form
DFC
202108-3015-002CF
Vaccine Status Form for Contractors & Visitors
Active
Certification of Vaccination Common Form
FDIC
202108-3064-002CF
Certification Vaccination Common Form - Visitors and Contractors
Active
Certification of Vaccination Common Form
TREAS/OCC
202110-1557-001CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
DOI/OS
202108-1093-001CF
DOI Certification of Vaccination Attestation Common Form (Contractors and Visitors)
Active
Certification of Vaccination Common Form
CPSC
202108-3041-002CF
CPSC Certification of Vaccination
Active
Certification of Vaccination Common Form
FMCS
202109-3076-001CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
ED/OM
202109-1880-001CF
Certification of Vaccination Form
Active
Certification of Vaccination Common Form
FTC
202109-3084-001CF
Certification of Vaccination Common Form
Active
Certification of Vaccination Common Form
DHS/TSA
202201-1652-002CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
IMLS
202108-3137-003CF
Certification of Vaccination Common Form
Active
Certification of Vaccination Common Form
NARA
202108-3095-001CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
NRC
202108-3150-002CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
DOL/DM
202108-1225-002CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
TVA
202108-3316-002CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
OGE
202108-3209-002CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
DOC/PTO
202108-0651-003CF
USPTO: Certification of Vaccination Common Form
Active
Certification of Vaccination Common Form
DOC/NTIA
202108-0660-003CF
FirstNet Certification of Vaccination (Contractors and Visitors)
Active
Certification of Vaccination Common Form
TREAS/DO
202110-1505-001CF
Certification of Vaccination Common Form - Treasury Department
Active
Certification of Vaccination Common Form
DOL/ETA
202108-1205-002CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
DOC/NIST
202108-0693-002CF
NIST Certification of Vaccination Attestation Common Form (Contractors and Visitors)
Active
Certification of Vaccination Common Form
DOC/NOAA
202108-0648-002CF
NOAA Certification of Vaccination Attestation Common Form (Contractors and Visitors)
Active
Certification of Vaccination Common Form
NIGC
202108-3141-003CF
Certification of Vaccine Form (NIGC)
Active
Certification of Vaccination Common Form
FERC
202109-1902-003CF
Certification of Vaccination Status
Active
Certification of Vaccination Common Form
SSS
202108-3240-002CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
FCC
202108-3060-001CF
Certification of Vaccination
Active
Certification of Vaccination Common Form
DOC/CENSUS
202108-0607-002CF
Census Bureau Certification of Vaccination
Active
Certification of Vaccination Common Form
PEACE
202109-0420-001CF
Certification of Vaccination for Visitors and On-Site Contractors
Active
Certification of Vaccination Common Form
AID
202108-0412-003CF
Certification of Vaccination Form
Active
Certification of Vaccination Common Form
ED/OM
202202-1880-002CF
Certification of Verification Form
Historical 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:
08/24/2021
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