View RCF  - OIRA Conclusion

202205-0690-001CF 202108-0690-002CF
Active 05/31/2025
DOC/OS OS
3206-0277 202202-3206-002
DOC/OS Certification of Vaccination Attestation Common Form (Contractors and Visitors)
RCF Recertification
 Approved   05/24/2022
Retrieve Notice of Action (NOA) 05/24/2022
DOC/OS 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 DOC/OS 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 DOC/OS. 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
 $161
Sheleen Dumas 202 482-3306 sdumas@doc.gov

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Certification of Vaccination Common Form 200 6 180 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 200 200 0 0 0 0
Annual Time Burden (Hours) 6 6 0 0 0 0
Annual Cost Burden (Dollars) 180 162 0 0 18 0

Yes
Miscellaneous Actions
No