View RCF - OIRA Conclusion

Title: Certification of Vaccination Common Form

Type of RCF: RCF Recertification
OIRA Conclusion Action: Approved	Conclusion Date: 05/24/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/24/2022
Terms of Clearance:

Description of Agency Usage: The form will be used by Visitors (i.e. General Public or Federal employees at other agencies) and IMLS contractors. Contractors and Visitors will have to retain (once completed) to show as requested for entry.

Authorizing Statute(s): None

Annual Cost to Federal Government:
Agency Contact: Connie Bodner 202 653-4636 cbodner@imls.gov

Common Form Information Collections (IC) in this RCF:

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Certification of Vaccination Common Form		100	3	90	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		100	3	90	Form and Instruction	CV2	Certification of Vaccination Common Form

RCF Summary of Burden:

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	100	100	0
Annual Time Burden (Hours)	3	3	0
Annual Cost Burden (Dollars)	90	81	9

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: