ACF will use this form to collect vaccination status from visitors and contractors to ACF headquarters, local and regional office buildings, and other spaces where services are provided or events take place.
None
Molly Buck 202 205-4724 mary.buck@acf.hhs.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
1,000
0
0
1,000
0
0
Annual Time Burden (Hours)
33
0
0
33
0
0
Annual Cost Burden (Dollars)
900
0
0
900
0
0
Yes
Miscellaneous Actions
No
This is a request for use of the Certification of Vaccination Common Form by ACF.