View RCF  - OIRA Conclusion

202108-1093-001CF
Active 05/31/2022
DOI/OS
3206-0277 202108-3206-003
DOI Certification of Vaccination Attestation Common Form (Contractors and Visitors)
RCF New
 Approved without change   08/31/2021
Retrieve Notice of Action (NOA) 08/31/2021
DOI 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 DOI 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 DOI. If that changes, an appropriate Privacy Act statement or other assurance of confidentiality, as appropriate, will be provided and request for use revised.
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
 
Jeffrey Parrillo 202 208-7072 jeffrey_parrillo@ios.doi.gov

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Certification of Vaccination Common Form 30,000 1,000 24,360 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 30,000 0 0 30,000 0 0
Annual Time Burden (Hours) 1,000 0 0 1,000 0 0
Annual Cost Burden (Dollars) 24,360 0 0 24,360 0 0

Yes
Miscellaneous Actions
No
This is a new use of the Vaccination Attestation common form with contractors and visitors for business purposes at DOI facilities.