Exhibit 3 COVID 19 Testing Attestation Form.docx
DOCX document 23 KB Posted
- Attached to
- Q22000573 Mold Remediation - AMP 38
- Solicitation number
- Q22000573
- Issued by
- Kauai County, Kaanapali CDP, Hawaii
About this file
This document is an Attestation Form related to COVID-19 testing requirements for contractors entering State of Hawaii facilities and properties, in accordance with Governor Ige's Executive Order 21-07. The form requires contractors and their employees to provide proof that they are fully vaccinated for COVID-19, or if partially vaccinated or unvaccinated, to provide a negative COVID-19 test result prior to commencing work. Employees must submit this attestation and provide a copy of their negative test results, which may be audited by the State. Partially vaccinated employees are subject to weekly testing until they become fully vaccinated.
The related state and local contract opportunity is for Mold Remediation Services at Hale Hoonanea under Asset Management Unit 38 on Kauai, Hawaii. The contract is being procured by the State of Hawaii. No additional details about the pricing, set asides, incumbents, funding, or other salient information are provided in the given documents.
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Other files
| File | Type | Posted |
|---|---|---|
| Exhibit 2 Contractor Attestation and Certification of Compliance.pdf | ||
| Photos Unit 3L Unit 3R.docx | DOCX document | |
| Exhibit 1 Wage Certificate.pdf | ||
| Scope of Services-Mold_Remediation_Hale_Hoonanea.pdf |
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Text version
ATTACHMENT B
(insert company letterhead)
COVID-19 Testing Attestation
As required in accordance with Governor Ige’s Executive Order 21-07 of September 9, 2021, as of Monday, September 13, 2021, all contractors and their employees entering State facilities and properties must provide proof that (i) they are fully vaccinated for COVID-19; or (ii) if partially vaccinated for COVID-19 (which includes receipt of one dose of a two-dose course of vaccination, completion of a single-dose vaccine less than two weeks ago. or completion of a single-dose vaccination less than two weeks ago) or unvaccinated, they received a negative test result of a COVID-19 test . An employee who is not fully vaccinated must provide this attestation of a negative COVID-19 test prior to the commencement of work.
The information provided must be accurate and complete to the best of the employee’s knowledge.
I understand that knowingly making a false statement on this form is a crime and can be punished by fine or imprisonment or both (HRS § 710-1063).
I understand and acknowledge my obligation to obtain and submit this attestation of a negative test result for COVID-19 from an FDA emergency use authorization antigen or nucleic acid amplification test completed by a CLIA certified laboratory or testing site prior to the commencement of work on HPHA property or facility.
I understand and acknowledge that my company and individual test results may be audited by the HPHA or other designated State representative at any time.
⃝ I have received a negative test result for COVID-19 based on a test sample taken from me not more than 72 hours prior to my entry to the HPHA property or facility and have provided or produced a copy of the test results to my employer.
⃝ I am partially vaccinated and intend to become fully vaccinated. I understand that I am subject to weekly testing and must submit a weekly testing attestation until two weeks after I become fully vaccinated.
Type of initial shot: Pfizer, Moderna, or Johnson & Johnson. (Circle One)
Date of initial shot: ___________________
Company Name of Contractor
| ___________________________________________ | _______________________ |
| Print Contractor Employee's Full Name | Date |
Contractor Employee's Signature
File details come from the government source that posted it. Updated .