Certification of Vaccination Common Form - Treasury Department
RCF New
The Department of the Treasury (including its Bureaus) will use this common form to gather vaccination status from onsite contractors and visitors at all Treasury facilities. This is in accordance with with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force and guidance from the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration.
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
$28,033
Spencer Clark 202 566-0729 clark.spencer@epa.gov
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Total Request
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
50,000
0
0
50,000
0
0
Annual Time Burden (Hours)
1,667
0
0
1,667
0
0
Annual Cost Burden (Dollars)
40,600
0
0
40,600
0
0
Yes
Miscellaneous Actions
No
This is a new form, required for compliance with EO 13991.