Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
This script provide functions for this page.
View RCF - OIRA Conclusion
RCF ID:
202108-1205-002CF
Previous RCF ID:
Status:
Active
Expiration Date:
05/31/2022
Agency/Subagency:
DOL/ETA
Agency Tracking No:
Host OMB Control No:
3206-0277
Host ICR Reference No:
202108-3206-003
Title:
Certification of Vaccination
Type of RCF:
RCF New
OIRA Conclusion Action:
Approved without change
Conclusion Date:
08/30/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/27/2021
Terms of Clearance:
Description of Agency Usage:
ETA will use this form to prevent the spread of COVID-19, and to protect the health and safety of all persons in DOL's Job Corps. Centers.
Authorizing Statute(s):
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
Annual Cost to Federal Government:
$0
Agency Contact:
Mara Blumenthal 202 693-8538 blumenthal.mara@dol.gov
Common Form Information Collections (IC) in this RCF:
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Certification of Vaccination Common Form
12,000
400
9,744
Form
3206-0277
Certification of Vaccination Common Form
Form and Instruction
OPM 5062
Certification Vaccination Employee
Form and Instruction
3206-0277
Certification Vaccination PRA
RCF 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
12,000
0
0
12,000
0
0
Annual Time Burden (Hours)
400
0
0
400
0
0
Annual Cost Burden (Dollars)
9,744
0
0
9,744
0
0
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 ETA's projected usage of the common form for the Job Corps. contractors.