Certification of Vaccination Common Form

Certification of COVID-19 Vaccination Status

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0277 can be found here:

Documents and Forms

Document Name Document Type
Form OPM 5062 Certification of Vaccination Common Form Form and Instruction
OPM 5062 Certification Vaccination Employee CertificationVaccinationEmployeesFinal.pdf Form and Instruction
OPM 5062 Certification Vaccination Employee CertificationVaccinationEmployeesFinal.pdf Form and Instruction
3206-0277 Certification of Vacination CertificationVaccinationPRAfinal_20220202.docx Form and Instruction
CV2 Certification of Vaccination Common Form CertificationofVaccinationCommonFormredline (pb 5.23.22)final.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Certification of Vaccination Common Form	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OPM 5062	Certification Vaccination Employee	CertificationVaccinationEmployeesFinal.pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	CV2	Certification of Vaccination Common Form	CertificationofVaccinationCommonFormredline (pb 5.23.22)final.docx		Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,952	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,952	2,452	1,500
Annual IC Time Burden (Hours)	132	82	50
Annual IC Cost Burden (Dollars)	3,558	2,340	1,218

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.