Certification of Vaccination

Forms and Documents

Document Name	Status
Form DOE F 231.2 Certification of Vaccination Form and Instruction	Modified
1910-5194 Supporting Statement- Final.docx Supporting Statement A	2022-07-07
30-day FRN 6-21-22.pdf Supplementary Document	2022-06-22
60-day FRN 3-17-22.pdf Supplementary Document	2022-05-31

IC Document Collections

IC ID	Document Title	Status
250968	Certification of Vaccination Form and Instruction	Modified

ICR Details

OMB Control No: 1910-5194	ICR Reference No: 202205-1910-006
Status: Received in OIRA	Previous ICR Reference No: 202112-1910-002
Agency/Subagency: DOE/DOEOA	Agency Tracking No: John Harris
Title: Certification of Vaccination
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/07/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2022
Responses	15,000	15,000
Time Burden (Hours)	2,505	2,505
Cost Burden (Dollars)	203,657	203,657

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Abstract: This information is being collected, and maintained in order to promote the safety of Federal buildings, the Federal workforce, and others on site at agency facilities consistent with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force, and guidance from the Centers for Disease Control and Prevention, and the Occupational Safety and Health Administration. Specifically, this information will be used by DOE staff charged with implementing and enforcing workplace safety protocols.

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

Citations for New Statutory Requirements: EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 15227	03/17/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 36841	06/21/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Certification of Vaccination	DOE F 231.2	Certificate of Vaccination

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ICR Summary of Burden

	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	15,000	15,000	0	0	0	0
Annual Time Burden (Hours)	2,505	2,505	0	0	0	0
Annual Cost Burden (Dollars)	203,657	203,657	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $232,057

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/07/2022

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