Exhibit 2 Contractor Attestation and Certification of Compliance.pdf

State of Hawaii Hawaii Public Housing Authority

Contractor Attestation and Certification of Compliance with the Governor’s Executive Order 21-07 for Access to State Properties

Contractor Name:

Contractor Street Address: Contractor Mailing Address:

Business Phone with Area Code:

Days and Hours of Operation:

Primary Point of Contact: Title:

Point of Contact Telephone:

Point of Contact Email:

Number of Full Time Employees Subject to Executive Order No. 21-07:

Number of Part Time Employees Subject to Executive Order No. 21-07:

Number of Volunteers Subject to Executive Order No. 21-07:

Number of Subcontractors Working Under This Contractor:

Number of Subcontractor Employees Subject to Executive Order No. 21-07:

Number of Other individuals representing Contractor Subject to Executive Order No. 21-07:

Describe Scope of Contract (e.g., Contract No., Location, Scope of Work):

9/12/21 1

Exhibit 2

By completing and submitting this Contractor’s Vaccination Attestation and Certification Form pursuant to the Governor’s Executive Order 2021-07, I acknowledge, agree and certify the following:

1. I am the owner of and/ or authorized agent for the business listed above.

2. I have read, understood, and agree to the requirements of the Governor’s Executive Order 21-07 and the Hawaii Public Housing Authority’s Policy on COVID-19 Vaccination and Testing Procedures for Contractors and Visitors and that the business as a vendor or contractor with the HPHA attests and certifies that all of its employees who are physically present/ located, at any HPHA property or facility, are fully vaccinated with the COVID-19 vaccination consistent with all applicable state and federal laws.

3. I understand and agree that all of our employees, who are partially vaccinated or non-vaccinated, are subject to regular weekly testing for COVID-19; and that as their employer I attest to and certify that the testing was performed, administered or observed by a laboratory, testing site, or healthcare provider or facility or authorized agent of the laboratory, testing site, or healthcare provider or facility of a sample taken not more than 72-hours prior to the start of the work week.

4. I agree that any employee, subcontractor employee, or volunteer shall be immediately removed from the HPHA’s property, facility or work site, if any of the conditions exist:

a. Employee fails to provide testing results within 72 hours;

b. Employee tests positive for COVID-19’;

c. Employee reports that they have had prolonged exposure to a COVID-19 positive individual and have not been cleared by their doctor to return to work or does not have a negative COVID-19 test to return to work;

d. Employee reports that they have COVID-19 symptoms; or

e. Employee has falsified or submitted a fraudulent COVID-19 vaccination card.

5. I have attached a list of all employees, subcontractor employees, volunteers, or other designated representatives who will access the HPHA’s properties or facilities and certify that I have verified their vaccination status and will submit weekly testing verification, if requested. I agree and understand that any changes in staff require immediate reporting to the HPHA.

6. I understand and agree that my business may be randomly audited by HPHA or other State authorized personnel for purposes of monitoring compliance with Executive Order 2021-07, and that I and/or the business or owners, managing member(s), partner(s) are subject to all penalties for violation of the Order.

I certify under penalty of perjury that the foregoing certification is true and correct, as executed by my signature on the date set forth below.

Date:

Print Full Name:

Signature:

*Attachment Required: Contractor Employees

9/12/21 2

Contractor or Subcontractor Employees

Please list the names and titles of all employees who will access the HPHA’s properties or facilities. (Attach additional pages as necessary.)

Contractor:

Employee Name Title/Position Vaccination Status

I certify under penalty of perjury that the information provided herein is true and correct, as executed by my signature on the date set forth below.

Print Full Name:

Signature: Date:

9/12/21 3