View RCF - OIRA Conclusion

Title: Certification of Vaccination

Type of RCF: RCF Recertification
OIRA Conclusion Action: Approved	Conclusion Date: 05/24/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/24/2022
Terms of Clearance:

Description of Agency Usage: The Department will use this form to prevent the spread of COVID-19, and to protect the health and safety of all persons in DOL buildings.

Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing

Annual Cost to Federal Government:
Agency Contact: Mara Blumenthal 202 693-8538 blumenthal.mara@dol.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		4,000	120	3,601	Form and Instruction	OPM 5062	Certification Vaccination Employee
Certification of Vaccination Common Form		4,000	120	3,601	Form and Instruction	CV2	Certification of Vaccination Common Form

RCF Summary of Burden:

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	4,000	4,000	0
Annual Time Burden (Hours)	120	120	0
Annual Cost Burden (Dollars)	3,601	3,248	353

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:

202205-1225-001CF