Attachment_11_-_Certification_of_Vaccination_Form.pdf

OMB Control No. 3206-0277 Exp. Feb. 28, 2025

Certification of Vaccination The purpose of this form is to take steps to prevent the spread of COVID-19 and to protect the health and safety of all Federal employees, onsite contractor employees, visitors to Federal facilities, and other individuals interacting with the Federal workforce. If you fail to submit this signed attestation, or if you are unable to provide proof of any required negative COVID-19 test, you may be denied entry to a Federal facility.

My COVID-19 Vaccination Status If you are not vaccinated against COVID-19 due to medical or religious reasons, please check either “I am not fully vaccinated against COVID-19” or “I decline to respond.”

By checking the box below, I declare that the following statement is true:

I am fully vaccinated against COVID-19. The Centers for Disease Control and Prevention (CDC) considers an individual fully vaccinated if they are: 2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine. If you don’t meet these requirements, regardless of your age, you are not fully vaccinated.

I am not fully vaccinated against COVID-19.

I decline to respond.

Federal COVID-19 Workplace Safety Protocols I understand that while in a Federal facility I must follow the COVID-19 workplace safety protocols required by the Federal agency I am visiting or for which I am performing contract work onsite. This includes wearing a mask when required in the facility, including when the COVID-19 Community Level in the county where the Federal facility is located is HIGH as defined by the CDC.

If I am not fully vaccinated or decline to provide my vaccination status, I understand the Federal agency I am visiting or for which I am performing contract work onsite may require that I be able to provide proof of a negative COVID-19 test I received within the previous 3 days, including when the COVID-19 Community Level in the county where the Federal facility is located is MEDIUM or HIGH as defined by the CDC.

I sign this document under penalty of perjury that the above is true and correct, and that I am the person named below. 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 if I am a Federal employee or contractor 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 or removal from a contract.

Printed name: ________________________________________________________________

Signature: _________________________________________ Date: _____________________

Directions and notice to Federal contractor employees When the COVID-19 Community Level in a county where a Federal facility is located is MEDIUM or HIGH as defined by CDC, onsite contractor employees must attest to their vaccination status by being able to present a completed Certification of Vaccination form while in that Federal facility. Please note that consistent with CDC guidance, agencies may have different or additional COVID-19 workplace safety protocols for individuals in specific work settings, such as healthcare or congregate settings, including protocols that vary based on an individual’s COVID-19 vaccination status.

You may be asked to show this form and/or information from a health screening upon entry to a Federal facility, and/or to a Federal employee who is supervising or managing your work on Federal premises. Please maintain this form during your time on Federal premises.

Please contact with questions.

Directions and notice to visitors When the COVID-19 Community Level in a county where a Federal facility is located is MEDIUM or HIGH as defined by the CDC, visitors must attest to their vaccination status by being able to present a completed Certification of Vaccination form while in that Federal facility. Please note that consistent with CDC guidance, agencies may have different or additional COVID-19 workplace safety protocols for people in specific work settings, such as healthcare or congregate settings, including protocols that vary based on an individual’s COVID-19 vaccination status.

You may be asked to show this form and/or information from a health screening upon entry to a Federal facility, and/or to a Federal employee who is sponsoring your visit. You may be asked to show this form as part of your in-person participation in a Federally hosted meeting, event, or conference. Please maintain this form during your visit.

If you are entering to obtain a public service or benefit and are not fully vaccinated, you must comply with all relevant CDC guidance, however using this form and following any requirement to show proof of a negative COVID-19 test do not apply to you.

Please contact with questions.

Directions and notice to Federal employees visiting a Federal agency other than their employing agency When the COVID-19 Community Level in a county where a Federal facility is located is MEDIUM or HIGH as defined by the CDC, Federal employees visiting a Federal agency other than their employing agency should be treated as visitors for the purposes of COVID-19 workplace safety protocols and should attest to their vaccination status by being able to present a completed Certification of Vaccination form while in that Federal facility. Please note that consistent with CDC guidance, agencies may have different or additional COVID-19 workplace safety protocols for people in specific work settings, such as healthcare or congregate settings, including protocols that vary based on an individual’s COVID-19 vaccination status.

You may be asked to show this form and/or information from a health screening upon entry to a Federal facility controlled by a Federal agency other than your employing agency, and/or to a Federal employee who is sponsoring your visit. You may be asked to show this form as part of your in-person participation in a meeting, event, or conference hosted by a Federal agency other than your employing agency. Please maintain this form during your visit.

Making a false statement on this form could result in an adverse personnel action against you, up to and including removal from your position.

Please contact with questions.

Privacy Notice We are authorized to request the information on this form pursuant to Executive Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021). You may be asked to show this form and/or information from a health screening upon entry to a Federal facility, and/or to a Federal employee at the agency you are visiting or at which you are working.

This is being done in order to promote the safety of Federal facilities and the Federal workforce consistent with the above-referenced Executive Order, guidance 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. This form and/or the information from a health screening will be returned to you and will not be maintained by the agency.

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.

Public burden information for employees, contractors, and visitors Public burden reporting for this collection of information is estimated to average 2 minutes per response, including time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to PRA@opm.gov. The OMB clearance number 3206-0277 is currently valid.

may not collect this information, and you are not required to respond, unless this number is displayed.