202108-3141-003CF RCF OMB: 3206-0277
OMB.report
OMB 3206-0277
RCF 202108-3141-003CF
( RCF Recertification )
Array
(
[refNbr] => 202108-3141-003CF
[obm] => 3206-0277
[icr] => 202108-3206-003
[status] => Active
[agency] => NIGC
[title] => Certification of Vaccine Form (NIGC)
[typeRCF] => RCF Recertification
[oiraAction] => Approved
[oiraNOA] => 357280
[termsOfClearance] =>
[previousRCF] => 202108-3141-002CF
[agencyTrackingNo] =>
[conclusionDate] => 2021-08-26
[dateReceived] => 2021-08-26
)
Document
View RCF
- OIRA Conclusion
RCF ID: 202108-3141-003CF
Previous RCF ID: 202108-3141-002CF
Status:
Active
Expiration Date: 02/28/2022
Agency/Subagency: NIGC
Agency Tracking No:
Host OMB Control No: 3206-0277
Host ICR Reference No: 202108-3206-003
Title: Certification of Vaccine Form (NIGC)
Type of RCF: RCF Recertification
OIRA Conclusion Action: Approved
Conclusion Date:
08/26/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/26/2021
Terms of Clearance:
Description of Agency Usage:
The NIGC will use this form to prevent the spread of COVID-19 and to
protect the health and safety of all Federal employees, onsite contractors,
visitors to Federal buildings or Federally controlled indoor workspaces, and
other individuals interacting with the Federal workforce.
Authorizing Statute(s):
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
EO: EO 12196 Name/Subject of EO: Occupational Safety and Health Program for Federal Employees
US Code:
5 USC Chapters 11 and 79
Annual Cost to Federal Government:
Agency Contact:
Tim Osumi 202 632-7054 tim_osumi@nigc.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
81
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
100
100
0
0
0
0
Annual Time Burden (Hours)
3
3
0
0
0
0
Annual Cost Burden (Dollars)
81
81
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: