View RCF - OIRA Conclusion

Title: Certification of Vaccination

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 Selective Service System Contractors and Visitors. Contractors and Visitors will have to retain (once completed) to show as requested for entry.

Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask Wearing

Annual Cost to Federal Government: $162
Agency Contact: Betty Lou Wingo 703 605-4005 BettyLou.Wingo@sss.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		200	6	180	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		200	6	180	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	200	200	0
Annual Time Burden (Hours)	6	6	0
Annual Cost Burden (Dollars)	180	162	18

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: