View RCF  - Agency Submission

202205-0970-001CF
Received in OIRA 05/31/2025
HHS/ACF ACF
3206-0277 202202-3206-002
Certification of Vaccination Form
RCF New
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.