The Environmental Protection Agency (EPA) 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 EPA 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 EPA. 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
Courtney Kerwin 202-566-1669
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
1,000
0
0
1,000
0
0
Annual Time Burden (Hours)
33
0
0
33
0
0
Annual Cost Burden (Dollars)
812
0
0
812
0
0
Yes
Miscellaneous Actions
No
This is a request for the EPA to utilize the Certificate of Vaccination Common Form to comply with EO 13991.