202205-3155-001CF RCF OMB: 3206-0277
OMB.report
OMB 3206-0277
RCF 202205-3155-001CF
( RCF Recertification )
Array
(
[refNbr] => 202205-3155-001CF
[obm] => 3206-0277
[icr] => 202202-3206-002
[status] => Active
[agency] => DNFSB
[title] => Certification of Vaccination
[typeRCF] => RCF Recertification
[oiraAction] => Approved
[oiraNOA] => 419980
[termsOfClearance] =>
[previousRCF] => 202108-3155-002CF
[agencyTrackingNo] => 202108-3155-001CF
[conclusionDate] => 2022-05-24
[dateReceived] => 2022-05-24
)
Document
View RCF
- OIRA Conclusion
RCF ID: 202205-3155-001CFPrevious RCF ID: 202108-3155-002CF
Status:
Active
Expiration Date: 05/31/2025
Agency/Subagency: DNFSBAgency Tracking No: 202108-3155-001CF
Host OMB Control No: 3206-0277Host ICR Reference No: 202202-3206-002
Title: Certification of Vaccination
Type of RCF: RCF Recertification
OIRA Conclusion Action: ApprovedConclusion Date:
05/24/2022
Retrieve Notice of Action (NOA)
Date Received in OIRA:
05/24/2022
Terms of Clearance:
Description of Agency Usage:
The form will be used by DNFSB contractors and visitors to document their vaccination status. They will retain the completed form to show as requested for entry.
Authorizing Statute(s):
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask Wearing
Annual Cost to Federal Government: $100
Agency Contact:
James Biggins 202 694-7014 jamesb@dnfsb.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
90
Form and Instruction
OPM 5062
Certification Vaccination Employee
Form and Instruction
CV2
Certification of Vaccination Common Form
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)
90
81
0
0
9
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: