B08_Attachment_3b_DOI_Memo_Certification_of_Vaccination_Form.pdf

OMB Control No. 3206-0277 Exp. Feb. 28, 2022

Certification of Vaccination The purpose of this form is to take steps to prevent the spread of COVID-19, to protect the health and safety of all Federal employees, onsite contractors, visitors to Federal buildings or Federally controlled indoor workspaces, and other individuals interacting with the Federal workforce. If you fail to submit this signed attestation or any required negative COVID-19 test, you may be denied entry to a Federal facility.

My Vaccination Status If you are not vaccinated due to medical or religious reasons, please check either “I have not been vaccinated” or “I decline to respond.”

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

I am fully vaccinated. The Centers for Disease Control and Prevention 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 yet fully vaccinated. Either I have received my first dose 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.

I understand that if I decline to respond or am not fully vaccinated, I must comply with the following safety protocols while in a Federal facility:

• Wear a mask regardless of the level of community transmission;

• Physically distance; and

• Provide proof of having received a negative COVID-19 test from within the previous 3 days if I am a visitor or I am an onsite contractor who is not enrolled in an agency’s testing program.

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:

Exp. Feb. 5, 2022

Directions and notice to Federal employees Consistent with guidance from the Centers for Disease Control and Prevention (CDC) and the Safer Federal Workforce Task Force, has established specific safety protocols for fully vaccinated people and not fully vaccinated people, respectively. You may be asked to submit this completed form to your employing agency.

In areas of low or moderate transmission, as defined by 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 settings. 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 are to prevent the spread of COVID-19 to protect the health and safety of our workforce. Making a false statement on this form could result in an adverse personnel action against you, up to and including removal from your position.

Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement informs you of why you are being asked to provide this information.

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 the 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.

Please contact with questions. Please return this form to .

Directions and notice to Federal contractors In areas of low or moderate transmission, as defined by 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 settings. In areas of high or substantial transmission, everyone, including fully vaccinated people, must wear a mask consistent with Federal requirements.

You may be asked to show this form and/or information from a health screening upon entry to a Federal building or Federally controlled indoor worksites, 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 In areas of low or moderate transmission, as defined by 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 settings. In areas of high or substantial transmission, everyone, including fully vaccinated people, must wear a mask consistent with Federal requirements.

You may be asked to show this form and/or information from a health screening upon entry to a Federal building or Federally controlled indoor worksites. Please maintain this form during 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. If you are entering to obtain a public service or benefit and are not fully vaccinated, you must comply with all relevant CDC guidance, including mask wearing and physical distancing requirements, however this form and the requirement to show a negative COVID-19 test do not apply to you.

https://www.federalregister.gov/documents/2010/06/21/2010-14838/privacy-act-of-1974-update-and-amend-system-of-records https://www.federalregister.gov/documents/2015/11/30/2015-30309/privacy-act-of-1974-routine-use-implementation-system-of-records

Public burden information 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.

mailto:PRA@opm.gov