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Active 02/28/2022
3206-0277 202108-3206-001
Census Bureau Certification of Vaccination
 Approved without change   08/16/2021
Retrieve Notice of Action (NOA) 08/16/2021
The Census Bureau 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 Census Bureau 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 Census Bureau. 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.
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
Mary Lenaiyasa 301 763-1015

IC Title Status Responses Hours Dollars Document Type Form No. Form Name

  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 3,600 0 0 3,600 0 0
Annual Time Burden (Hours) 120 0 0 120 0 0
Annual Cost Burden (Dollars) 2,923 0 0 2,923 0 0

Miscellaneous Actions
This is a request for the Census Bureau to utilize the Certificate of Vaccination Common Form to comply with EO 13991.