View RCF  - OIRA Conclusion

202205-0660-002CF 202108-0660-004CF
Active 05/31/2025
DOC/NTIA
3206-0277 202202-3206-002
NTIA Certification of Vaccination (Contractors and Visitors)
RCF Recertification
 Approved   05/24/2022
Retrieve Notice of Action (NOA) 05/24/2022
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.
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and REquiring Mask-Wearing
 
Diana Moreno 202 482-1034 dmoreno@ntia.gov

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Certification of Vaccination Common Form 150 4 135 Form and Instruction OPM 5062 Certification Vaccination Employee
Form and Instruction CV2 Certification of Vaccination Common Form

  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 150 150 0 0 0 0
Annual Time Burden (Hours) 4 4 0 0 0 0
Annual Cost Burden (Dollars) 135 122 0 0 13 0

Yes
Miscellaneous Actions
No