View RCF  - OIRA Conclusion

202110-1505-001CF
Active 05/31/2022
TREAS/DO
3206-0277 202108-3206-003
Certification of Vaccination Common Form - Treasury Department
RCF New
 Approved without change   10/17/2021
Retrieve Notice of Action (NOA) 10/13/2021
The Department of the Treasury (including its Bureaus) will use this common form to gather vaccination status from onsite contractors and visitors at all Treasury facilities. This is in accordance with 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.
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
 $28,033
Spencer Clark 202 566-0729 clark.spencer@epa.gov

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Certification of Vaccination Common Form 50,000 1,667 40,600 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 50,000 0 0 50,000 0 0
Annual Time Burden (Hours) 1,667 0 0 1,667 0 0
Annual Cost Burden (Dollars) 40,600 0 0 40,600 0 0

Yes
Miscellaneous Actions
No
This is a new form, required for compliance with EO 13991.