C04.11 - Attachment J-11 Facility Access Addendum 10Jan2022.pdf

DEPARTMENT OF THE NAVY

PUGET SOUND NAVAL SHIPYARD

AND INTERMEDIATE MAINTENANCE FACILITY

1400 FARRAGUT AVENUE STOP 2090

BREMERTON WASHINGTON 98314-2090 IN REPLY REFER TO:

Ser 400/007

January 10, 2022

Contractor Distribution

Dear Sir or Madam:

SUBJECT: CORONAVIRUS DISEASE 2019 VACCINATION ATTESTATION,

SCREENING TESTING, AND VACCINATION VERIFICATION

Reference: (a) Force Health Protection Guidance (Supplement 23) Revisions 3 – Department of Defense Guidance for Coronavirus Disease 2019 Vaccination Attestation, Screening Testing, and Vaccination Verification

The purpose of this letter is to put you on notice of a change to the facility access requirements for Department of Defense (DoD) facilities. In accordance with reference (a), the following access requirements are being implemented to reduce the transmission of the virus that causes coronavirus disease 2019 (COVID-19). Starting January 18, 2022, DoD contractor personnel (to include but not limited to service contractors, repair yard personnel, contract technical support, etc.) that require access to DoD facilities (including ships and submarines) at the Public Naval Shipyards, Regional Maintenance Centers and naval installations, or private repair yards, the following applies:

1. For DoD contractor personnel, the DoD civilian vaccination deadline of 22

November 2021, does not apply.

2. DoD contractor personnel will complete and maintain a current copy the DD Form

3150, “Contractor Visitor Certification of Vaccination” enclosure (1) and show it to authorized

DoD personnel upon request. Failure to present the DD form 3150 may result in denying contractor personnel access to the DoD facilities to which access is sought.

3. DoD contractor personnel, who are not fully vaccinated against COVID-19, as identified on DD form 3150, will also maintain a copy of “Weekly attestation of Negative Covid-

19 Self-Certification for DoD Contractors” enclosure (2) that shows a test was administered within the last seven days and show it to authorized DoD personnel upon request. DoD contractor personnel who refuse required screening tests will be denied access to DoD facilities.

It is the responsibility of the contractor to provide to the government proof of vaccination or attestation of negative test results for their personnel working in DoD facilities or private shipyards as outlined above. Failure to present the required proof will result in denying the respective contractor personnel access to the requested DoD facility.

This notice is to provide contractors with the facility access requirements and does not constitute a change to an existing contract terms and conditions.

Ser 400/007

January 10, 2022

Please contact your Contracting Officer or your facility access sponsor if you have questions regarding this guidance.

D. C. CROW

Chief of the Contracting Office

Enclosures: 1. DD Form 3150 (Oct 2021)

2. Weekly Attestation of Negative COVID-19 Self-Certification for DoD

Contractors

CONTRACTOR PERSONNEL AND VISITOR CERTIFICATION OF VACCINATION

AGENCY DISCLOSURE NOTICE

0MB No. 0704--0613

&piralion: 20220228

The public reporting burden for this collection of information is estimated to average 2 minutes per response, including the lime for reviewing nstructions, searching existing data sources. gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of infom1ation, including suggestions for reducing the burden, to the Department of Defense.

Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-informationcolleclions@mail.mil. Respondents should be aware that notwithstanding any other provision of law. no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid 0MB control number.

PRIVACY ACT STATEMENT

Authority: DoD is authorized to collect the information on this form pursuant to Executive Order (E.0.} 14042. Ensuring Adequate COVID Safety Protocols for Federal Contractors; E.O. 13991. Protecting the Federal Workforce and Requiring Mask-Wearing; and E.O. 12196, Occupational Safety and Health Program for Federal Employees; as well as 10 U.S.C. 113, 10 U.S.C. 136, 10 U.S.C. 7013, 10 U.S.C. 8013, 10 U.S.C. 9013, 10 U.S.C. 2672. 5 U.S.C. chapter 79, and DoD Instruction 6200.03, Principal Purpose: This information is being collected to implement Coronavirus Disease 2019 (COVID-19) wor�place safely plans, including DoD's COVID-19 testing programs, and to ensure the safety and protection of the DoD workforce, workplace, and other DoD faciltties and environments, consistent with the above-referenced authorities. the COVID-19 Workplace Safety: Agency Model Safety Principles estat>lished by the Safer Federal Workforce Task Force, and guidance from the Centers for Disease Control and Prevention and the Occupational Safety ancl Health Administration, Routine Use(s): While the information requested on this form is intended to be used primariy for internal purposes, in certain circumstances it may be necessary lo disdose this information externally, for example to disclose information to: a person, organization, or governmental entrty as necessary and relevant lo notily them of. respond to, or gu.ird against a public health emergency or other simiar eris s, induding to comply wilh laws governing the reporting of communicable disease or other laws concerning health and safely in the work environment: adjudicat,ve or admin strative bodies or officials when the records are relevant and necessary to an adJud1cative or administrative proceeding; contractors, grantees, experts, consultants, students, and others as necessary to perform their duties for the Federal government; agencies, courts, and persons as necessary and relevant in the course of litigation, and as necessary and in accordance wtth requirements for law enforcement; or to a person authorized to act on your behalf. A complete list of routine uses may be found in the applicable System of Records Notice (SORN) associated with the colledion of this information from contractor personnel and DoO visitors; DPR 39 DoD, DoD Personnel Accountability and Assessment System of Records. 85 Fed. Reg. 17047 (Mar. 26, 2020) (also available at https://dpcld.defense.govlPortals/49I Documents/Privacy/SORNslOSDJSIDPR-39-0oD.pdf).

Consequences of Failure to Provide Information: Providing this 1nforrnatio11 is voluntary. However, if you fail lo provide this information, you will be treated as not fully vaccinated for purposes of implementing safely measures, including subject lo COVID-19 screening testing and/or denied access to DoD facilities.

Faijure to prov de such informaliOn may also hinder DoO's ab,hly to implement COVID-19 workplace safety plans, thereby increasing the health or safety risk to DoD-affiliated personnel and DoD facilit es.

INSTRUCTIONS: This form should be completed by OoD contractor personnel and official visitors in accordance with current OoD Force Health Protection Guidance. DoD civilian employees should not complete this form.

1. NAME (Last. First, Ml): 2. DoD ID NUMBER:

3, PLEASE CHECK THE BOX BELOW THAT COINCIDES WITH YOUR COVID•19 VACCINATION STATUS

I am fully vaccinated.

Individuals are considered 'fully vaccinated" two weeks after completing the second dose of a two-dose COVID-19 vaccine or two weeks after receiving a singe dose of a one-dose vaccine. Accepted COVID-19 vaccines are those which have received a license or emergency use authorization from the U.S. Food and Drug Administration c1nd those COVID-19 vaccines on the World Health Organization Emergency Use Listing.

'Fully vaccinated" also Includes circumstances in which the individual was a participant in a U.S. site clinical trial and has received all recommended doses.

I am not yet fully vaccinated. I received only one dose of an accepted two-dose COVID-19 vaccine. or I received my final dose of an accepted COVID-19 vaccine less than two weeks ago.

I have not been vaccinated.

I dedine lo respond.

Individuals who choose not lo 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 ·1 have not been vaccinated" or 1 dedine 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.

D I certify that the information prov,ded 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 impr sonment or both ( 18 U .S.C. 1001 ). Checking ·1 decline to respond" does not constitute a false statement

4.. DA TE (YYYYMMDD) S. SIGNATURE (Fu// Name}

DD FORM 3150, OCT 2021 CUI (when filled in) Conll'olled by: OUSO(P&R) Conll'Olled by ASD(HA)

Page 1 of1

CUI Category: HLTH: PRVCY; OPSEC

Enclosure (1)

CUI (when filled in)

�Ett WEEKLY ATTESTATION OF NEGATIVE

COVID-19 SELF-CERTIFICATION FOR DoD CONTRACTORS !,hl'AL &FA SYSTEMS CO"IIAND

PRIVACY ACT STATEMENT

·ty: Pursuant ID 5 U.S.C. chapter.; 11 and 70, and in discharging tt,e funcbcns dll'l!Cllld under Executive Order 14043, Requiring COl'Dllavirus ase 2010 Vaccination for Federal E� (Sept. 0. 2021 ). DoO is authorized 10 oollect this information. Adcfllicnal aulhorities for the systems of assoc:iatl!d wilh this collection of i'lfonnation also inckJde: E.O. 13001, Protecting the Federal Workforce and Requiring Mask-Wearing: E.O.

2106. Occupational Safety and Heallh Program for Federal Employees; 10 U.S.C. 113. 10 U.S.C. 136, 10 U.S.C. 7013, 10 U.S.C. 8013, 10 U.S.C.

13. 10 U.S.C. 26n; DoD Directive 5525.21; and DoD Instruction 6200.03. Providing this infcnnation is rnandaio,y and OoD is authorized to inpose allies for fa'ue 10 provide the i1foonation pursuant ID applicable Federal personnel laws and regulations.

rincipal Purpose: This infonnalion is being collected and maintained ID inplement Cmlnawus Oi5ease 2019 (COVID-10) wcrkplace safety plans.

nd enwre the safely and protection of the DoO watforce, workplace, and other DoD facilities and environments, consistent with the abo'lle-merenced uthorities, the COVID-10 Wonplace Safety: Agency Model Saf'ety Principles established by the Safer Fedef'al Wortfon:e Task Fon:e. and guidance the Cent&B for Disease Control and Prevention and the Occupabonal Safety and Health Adrninistrabcn.

outine lJsels): While the infumalion reque,sled on this fonn is intended ID be used primariy for internal purposes, in certain circumstances it may be oessary ID disclose this infcnnation externally. for example 10 dlSClose information to: a person, orvanizalion or governmental entity as necessary and levant to notify them of, respond ID. or guard against a public health emergency, or oeher similar crisis, incbling to campy with laws governing the · of cormiunicable disease or other laws concerning health and safety rt the work environment; adjudicative boc&!s (e.g. the Merit S)'Slem rotection Boiwd), arbitralDB, and huring examiners to the extent necessary to carry out lhK aulhorized duties regarding Federal e�,t;

clln, grantees. e,cperts, consultants, students. and oChln as necessary to perbm their duties for the Federal government or agencies. c:ourts, nd per.;ons as necessary and relevant in the C:OUr5e of rlligation. and as in ac:oordance wl1h requirements ror law enforoement; or 1D a person uthorized to act on )'Ol.lr behalf.

complete list of routme u5e5 may be fcund in the applicable S}'51em of Records Notice (SORN) associated with the collection of this inlo!TllillJon as : For most Federal c:ivmn �loyees: OPMIGOVT-10. Employee Medical Re S)'Slem Records, 75 Fed. Reg. 35000(Jun. 21, 2010), amended

Fed. Reg. 74815 (Nov. 30, 2015). For Federal ciYNn �loyees not covered by OPM/GOVT-I0: OPR 39 DoO. OoD Personnel Acooun1ability and ssment System of Records. 85 Fed. Reg. 17047 (Mar. 26.2020) (also available at htlps://dpcid.defense.gOVJPor1alsJ4QIDocu'llents/Privacy/

ORN�OJSIDPR-39-DoD.pdf).

ons@QUenc:es of Failure to Provide Information: Providing this rtformation is mandaloly. Failure to provide this inforrnabon or prowfng false nfamation may. at a minirrun, prevent access by the contractor and/or contracted personnel to OoD ·es (to include ships and submarines).

The Results From My COVID-19 Test Are: EJ

For The Week Starting On:

Date Of Negative Test Report To Wort Date:

certify that the ,nfonnation I have provided on this form and the pool of vaccination documentation I have submitted is true and carect. I understand a tnowrtg and willful fal5e statement on this form c:an be pulllShed by fine or imprisonment or boch (18 U.S.C. 1001).

PmtedName Soi,lature Field: 1 Date:

Page 1 of I

Enclosure (2)