COVID-19 Vaccination Attestation Form

ICR 202108-0704-008

OMB: 0704-0613

Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
202108-0704-008
Received in OIRA
DOD/DODDEP
COVID-19 Vaccination Attestation Form
New collection (Request for a new OMB Control Number)   No
Emergency 08/25/2021
08/24/2021
  Requested Previously Approved
6 Months From Approved
3,500,000 0
116,667 0
3,150,000 0

This information is being requested in order to promote the safety of individuals in Federal buildings and on DoD installations, consistent with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force and guidance from the CDC and the Occupational Safety and Health Administration. This information will be used by DoD staff charged with implementing and enforcing workplace safety protocols and is required for ensuring compliance with the requirement for attestation by all civilian employees, on-site contractors, and official visitors. Vaccination status for Military Service members will be obtained by alternate means using DoD’s Individual Medical Readiness system.
Consistent with guidance from the Centers for Disease Control and Prevention (CDC), and guidance from the Safer Federal Workforce Task Force established pursuant to Executive Order 13991, “Protecting the Federal Workforce and Requiring Mask-Wearing” (January 20, 2021), the Department of Defense (DoD) is establishing specific safety protocols concerning individuals fully vaccinated and not fully vaccinated against coronavirus disease 2019 (COVID-19). Individuals who attest that they are not fully vaccinated against COVID-19 or who choose not to provide this information will be required to comply with applicable CDC and DoD guidance for individuals not fully vaccinated against COVID-19, including wearing masks regardless of the transmission rate in a given area, physical distancing, regular screening testing, and adhering to applicable travel requirements

None
None

Not associated with rulemaking

No

1
IC Title Form No. Form Name
COVID-19 Vaccination Attestation Form DD 3150 Certification of Vaccination

  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 3,500,000 0 0 3,500,000 0 0
Annual Time Burden (Hours) 116,667 0 0 116,667 0 0
Annual Cost Burden (Dollars) 3,150,000 0 0 3,150,000 0 0
Yes
Miscellaneous Actions
No
New collection with a new associated burden

$98,900,000
No
    Yes
    Yes
No
No
No
No
Brandon Kim 703 344-6832 brandon.h.kim8.ctr@mail.mil

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/24/2021


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