Vaccination_Certification_Form-Fillable_Employees.pdf

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Self-Certification of Vaccination Status by USDA Employees Version 1.0

Important: Completion of this form is voluntary and applies only to Federal employees (i.e., does not apply to contracting staff).

Consistent with guidance from the Centers for Disease Control and Prevention (CDC) and the Safer Federal Workforce Task Force, the US Department of Agriculture is establishing specific safety protocols for fully vaccinated people and not fully vaccinated people, respectively.

In areas of low or moderate transmission, as defined by the CDC, fully vaccinated people generally can safely participate in most activities, indoor or outdoor, without needing to wear a mask or maintain physical distance, and do not need to undertake regular testing. Please note that, consistent with CDC guidance, agencies may have different protocols for fully vaccinated people in specific work settings, such as healthcare. In areas of high or substantial transmission, everyone, including fully vaccinated people, must wear a mask consistent with Federal requirements.

Employees who disclose that they are fully vaccinated will comply with agency guidance for fully vaccinated individuals. Employees who are unvaccinated, are not fully vaccinated, or who choose not to provide vaccine information are required to comply with CDC and agency guidance for not fully vaccinated individuals, including wearing masks regardless of the transmission rate in a given area, physical distancing, regular testing, and adhering to applicable travel restrictions. These requirements help prevent the spread of COVID-19 to protect the health and safety of our workforce.

Pursuant to this policy, the Certification of Vaccination form for you to complete starts on the next page.

Please contact your Pandemic Coordinator with questions or if you need to update this form at a later date.

United States Department of Agriculture Certification of Vaccination

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Certification of Vaccination

Please check the box below that coincides with your vaccination status and return this attestation form, by August 31st, to:

Employee’s First-Line Supervisor: ________________________________

I am fully vaccinated.

Employees are considered “fully vaccinated” two weeks after completing the second dose of a two-dose COVID-19 vaccine (e.g., Pfizer or Moderna) or two weeks after receiving a single dose of a one-dose vaccine (e.g., Johnson & Johnson/Janssen).

I am not fully vaccinated; I received my first does of Moderna or Pfizer, and my second appointment is scheduled, or I received my final dose less than two weeks ago.

I have not been vaccinated.

I decline to respond.

Employees who choose not to complete the form will be assumed to be not fully vaccinated for purposes of application of the safety protocols. If you are not vaccinated due to medical or religious reasons, please check either “I have not been vaccinated” or “I decline to respond.” Note that if you have already received one dose of a vaccine, but are not yet fully vaccinated, or if you received your final dose less than two weeks ago, then you will be treated as not fully vaccinated until you are at least two weeks past your final dose and resubmit your vaccination information.

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I attest that the information provided in this form is accurate and true to the best of my knowledge.

I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. 1001).

Checking “I decline to respond” does not constitute a false statement. I understand that making a false statement on this form could result in additional administrative action including an adverse personnel action up to and including removal from my position.

Your printed name here

Employee Signature Date Signed

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Certification of Vaccination for Federal Employees

Privacy Act Statement

Authority: We are authorized to collect the information requested on this form pursuant to Executive Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), Executive Order 12196, Occupational Safety and Health Program for Federal Employees (Feb. 26, 1980), and 5 U.S.C. chapters 11, and 79.

Purpose: This information is being collected and maintained to promote the safety of Federal buildings and the Federal workforce consistent with the above-referenced authorities, the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force, and guidance from Centers for Disease Control and Prevention and the Occupational Safety and Health Administration.

Routine Uses: While the information requested on this form is intended to be used primarily for internal purposes, in certain circumstances it may be necessary to disclose this information externally, for example to disclose information to: a Federal, State, or local agency to the extent necessary to comply with laws governing reporting of communicable disease or other laws concerning health and safety in the work environment; to adjudicative bodies (e.g., the Merit System Protection Board), arbitrators, and hearing examiners to the extent necessary to carry out their authorized duties regarding Federal employment; to contractors, grantees, or volunteers as necessary to perform their duties for the Federal Government; to other agencies, courts, and persons as necessary and relevant in the course of litigation, and as necessary and in accordance with requirements for law enforcement; or to a person authorized to act on your behalf. A complete list of the routine uses can be found in the system of records notice associated with this collection of information, OPM/GOVT-10, Employee Medical File System of Records, 75 Fed. Reg. 35099 (June 21, 2010), amended 80 Fed. Reg. 74815 (Nov. 30, 2015).

Consequence of Failure to Provide Information: Providing this information is voluntary. However, if you fail to provide this information, you will be treated as not fully vaccinated for purposes of implementing safety measures, including with respect to mask wearing, physical distancing, testing, travel, and quarantine.

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Revision History

Version Date By Notes

0.1 6/30/21 Nathan Harvey, Sara Bleich Initial draft.

0.2 7/12/21 Debra Buescher Formatted and edited for hard copy.

0.3 7/27/21 Debra Buescher Revised and edited for hard copy.

0.4 8/10/21 Debra Buescher Revised and edited text per Sara Bleich.

0.5 8/17/21 Keith Sessions Minor edits and format revisions. Converted to PDF form. Fillable fields added.

1.0 8/18/21 Keith Sessions Final edits made. Final version published.

Revision History