View RCF - OIRA Conclusion

Title: NTIA Certification of Vaccination (Contractors and Visitors)

Type of RCF: RCF New
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/19/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/19/2021
Terms of Clearance:

Description of Agency Usage: The National Telecommunications and Information Administration (NTIA) 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 NTIA staff charged with implementing and enforcing workplace safety protocols when requesting attestation of vaccination status from contractors and visitors. The information collected on this form is not being collected, maintained, or retained by NTIA. If that changes, an appropriate Privacy Act statement or other assurance of confidentiality, as appropriate, will be provided and request for use revised.

Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and REquiring Mask-Wearing

Annual Cost to Federal Government:
Agency Contact: Diana Moreno 202 482-1034 dmoreno@ntia.gov

Common Form Information Collections (IC) in this RCF:

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

RCF Summary of Burden:

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	150	150
Annual Time Burden (Hours)	5	5
Annual Cost Burden (Dollars)	122	122

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: The burden requested reflects the projected usage of this common form for NTIA.