View RCF
- OIRA Conclusion
RCF ID: 202108-1103-002CFPrevious RCF ID: 202108-1103-001CF
Status:
Active
Expiration Date: 02/28/2022
Agency/Subagency: DOJ/DOJADMAgency Tracking No:
Host OMB Control No: 3206-0277Host ICR Reference No: 202108-3206-003
Title: Vaccine Attestation Form
Type of RCF: RCF Recertification
OIRA Conclusion Action: ApprovedConclusion Date:
08/26/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/26/2021
Terms of Clearance:
Description of Agency Usage:
The Department has been directed to ask about the vaccination status of Federal employees and onsite contractors. Employees and onsite contractors must sign an attestation confirming their vaccine status. Visitors must demonstrate information on their vaccine status, unless they are entering to obtain a public service or benefit.
Authorizing Statute(s):
None
Annual Cost to Federal Government:
Agency Contact:
Melody Braswell 202 307-0890 melody.braswell2@usdoj.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
2,000,000
60,000
1,624,000
Form
3206-0277
Certification of Vaccination Common Form
Form and Instruction
OPM 5062
Certification Vaccination Employee
Form and Instruction
3206-0277
Certification Vaccination PRA
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
2,000,000
2,000,000
0
0
0
0
Annual Time Burden (Hours)
60,000
66,667
0
0
-6,667
0
Annual Cost Burden (Dollars)
1,624,000
1,624,000
0
0
0
0
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: