View RCF  - OIRA Conclusion

202205-2030-001CF 202108-2030-002CF
Active 05/31/2025
EPA/OMS
3206-0277 202202-3206-002
Certification of Vaccination Common Form
RCF Recertification
 Approved   05/24/2022
Retrieve Notice of Action (NOA) 05/24/2022
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
Certification of Vaccination Common Form 1,000 30 900 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 1,000 1,000 0 0 0 0
Annual Time Burden (Hours) 30 30 0 0 0 0
Annual Cost Burden (Dollars) 900 812 0 0 88 0

Yes
Miscellaneous Actions
No