View RCF  - OIRA Conclusion

202108-0651-003CF 202108-0651-001CF
Active 05/31/2022
DOC/PTO
3206-0277 202108-3206-003
USPTO: Certification of Vaccination Common Form
RCF Recertification
 Approved   08/26/2021
Retrieve Notice of Action (NOA) 08/26/2021
USPTO 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 USPTO personnel charged with implementing and enforcing workplace safety protocols when requesting attestation of vaccination status from onsite contractors and visitors. This form is not being collected, maintained, or retained by USPTO. 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
 $17,600
Anne Mendez 571 272-9600

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Certification of Vaccination Common Form 1,400 42 1,137 Form 3206-0277 Certification of Vaccination Common Form
Form and Instruction OPM 5062 Certification Vaccination Employee
Form and Instruction 3206-0277 Certification Vaccination PRA

  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 1,400 1,400 0 0 0 0
Annual Time Burden (Hours) 42 47 0 0 -5 0
Annual Cost Burden (Dollars) 1,137 1,137 0 0 0 0

Yes
Miscellaneous Actions
No