Force Health Protection Guidance (supplement 23) Revision 2 Updated.pdf

UNDER SECRETARY OF DEFENSE

4OOO DEFENSE PENTAGON

WASHtNGTON, D.C. 20301-4000 ocT 2 e 202t

PERSONNEL AND

READINESS

MEMORANDUM FOR SENIOR PENTAGON LEADERSHIP

COMMANDERS OF THE COMBATANT COMMANDS

DEFENSE AGENCY AND DOD FIELD ACTIVITY DIRECTORS

SUBJECT: Force Health Protection Guidance (Supplement23) Revision 2 - Department of Defense Guidance for Coronavirus Disease 2019 Vaccination Attestation, Screening Testing, and Vaccination Verification

This memorandum rescinds and replaces reference (a),1 and provides updated guidance for implementing additional force health protection and worþlace safety measures directed by the White House Safer Federal Workforce Task Force (reference (b)) to reduce the transmission of the virus that causes coronavirus disease 2019 (COVID-l9).

In accordance with references (b), (c), and (d), DoD civilian employees are now required to be fully vaccinated by November 22,2021, subject to exemptions as required by law. For purposes of this guidance, "DoD civilian employee," includes foreign nationals employed by DoD outside the United States, to the maximum extent possible while respecting host nation agreements and laws. It also includes DoD civilian employees who are engaged in fuIl-time telework or remote work. Additional information about the requirements for DoD civilian employees can be found in Attachment 1.

DoD contractor personnel and official visitors must attest to being fully vaccinated and, if not fully vaccinated, present the results of a recent negative COVID-19 test as a condition of physical access to DoD buildings and DoD-leased spaces in non-DoD buildings in which official DoD business takes place (referred to jointly in this memorandum as "DoD facilities"). For purposes of this physical access requirement, "contractor personnel" are those individuals issued a credential by DoD that affords the individual recurring access to DoD facilities, classified herein as "credentialed recurring access" (CRA) (e.g., Common Access Cardholders). "Official visitors" are non-DoD individuals seeking access, one time or recurring, in association with the performance of official DoD business (e.g., to attend a meeting), but who do not have CRA. The COVID-19 vaccination status for all individuals with CRA and official onsite visitors will be determined in accordance with Attachment 2.

These vaccination and physical access requirements do not apply to personnel receiving ad hoc access to DoD facilities (e.g., delivery personnel, taxi services); to individuals who have access to the grounds of, but not the buildings on, DoD installations (e.g., contract groundskeepers, fuel delivery personnel, household goods transportation personnel); to personnel accessing DoD buildings unrelated to the performance of DoD business (e.g., residential housing); or to personnel accessing DoD facilities to receive a public benefit (e.g., commissary;

I References are listed in Attachment 10.

exchange; public museum; air show; military medical treatment facility; Morale, Welfare, and Recreation resources).

In accordance with reference (e), Service members (members of the Armed Forces under DoD authority on active duty or in the Ready Reserve, including members of the National Guard) are required to be fully vaccinated against COVID-19. Service members' vaccination status will be validated utilizing their Military Service-specific Individual Medical Readiness (IMR) system. If a Service member has been vaccinated against COVID-I9 outside the Military Health System, that Service member must show official proof of his or her COVID-I9 vaccination status to update the IMR system. Once the applicable mandatory vaccination date has passed, COVID-I9 screening testing as described in Attachment 7 is required at least weekly for Service members who are not fully vaccinated, including those who have an exemption request under review, or who are exempted from COVID-I9 vaccination and arc entering a DoD facility. Service members who are not on active duty and who also are DoD civilian employees or DoD contractor personnel must follow the applicable requirements in this memorandum for DoD civilian employees or DoD contractor personnel, as the case may be. Service members not on active duty must comply with any other applicable DoD or DoD Component guidance.

Individuals are considered fully vaccinated 2 weeks after completing the second dose of a two-dose COVID-l9 vaccine or 2 weeks after receiving a single dose of a one-dose COVID-I9 vaccine. Individuals must be vaccinated with vaccines that are either fully licensed or authorized for emergency use by the Food and Drug Administration (FDA) (e.g., Pfizer- BioNTech/COMIRNATY, Moderna, Johnson & Johnson/Janssen vaccines); listed for emergency use on the World Health Organization Emergency Use Listing (e.g., AstraZeneca/Oxford); or approved for use in a clinical vaccine trial for which vaccine efficacy has been independently confirmed (e.g., Novavax). Those with previous COVID-l9 infection(s) or antibody test results are not considered fully vaccinated on that basis for the purposes of this memorandum.

All medical and other information collected from individuals will be maintained in a manner meeting the privacy requirements in Attachment 9.

The Secretaries of Military Departments and the Director of Administration and Management for all other DoD Components will publish any necessary supplemental instructions and ensure that all contract and associated funding implications are considered.

DoD Components should engage with DoD civilian employee unions as they develop supplemental guidance and otherwise satisfy any applicable collective bargaining obligations under the law at the earliest convenience, including on a post-implementation basis.

This memorandum and other COVID-19 guidance memoranda are centrally located at:

https://www.defense.gov/Spotlights/Coronavirus-DOD-Response/Latest-DOD-Guidance/

Please direct any questions or comments to the following email address: dha.ncr.ha-support. li st.policy-hrpo-kmc-owners@mail.mil.

Gilbert R. Cisneros, Jr

Attachments:

1. ATTACHMENT 1: Vaccination Requirements for DoD Civilian Employees

2. ATTACHMENT 2: Requirements for DoD Contractor Personnel, Official Onsite Visitors, and Others Seeking Access to Facilities

3. ATTACHMENT 3: DD Form 3175 - "DoD Civilian Employee Certification of

Vaccination"

4. ATTACHMENT 4: DD Form 3150 - "Contractor and Visitor Certification of Vaccination"

5. ATTACHMENT 5: DD Form 3176 - "Request for a Medical Exemption or Delay to the

COVID- I 9 Vaccination Requirement"

6. ATTACHMENT 6: DD Form 3177 - "Request for a Religious Exemption to the COVID-l9

Vaccination Requirement"

7. ATTACHMENT 7: COVID-I9 Screening Testing Requirements

8. ATTACHMENT 8: Requirements for Obtaining Self-Collection Kits and Self-Tests

9. ATTACHMENT 9: Privacy Requirements

10. ATTACHMENT 10: References

J

ATTACHMENT 1

Vaccination Requirements for DoD Civilian Employees

1. Vaccination Requirement

a. DoD civilian employees who are not currently fully vaccinated must meet or have met the following deadlines, if using vaccines that are fully licensed or authoized for emergency use by the FDA, in order to be fully vaccinated by November 22,2021:

i. October l1: first dose deadline (if receiving the Moderna vaccine);

ii. October 18: first dose deadline (if receiving the Pftzer-

BioNTech/COMIRNATY vaccine) ;

iii. November 8: second dose deadline (if receiving the Moderna and Pfi zerBioNTech/COMIRNATY vaccines) ;

iv. November 8: first (only) dose deadline (if receiving the Johnson & Johnson/Janssen vaccine); and

v. If DoD civilian employees use an authorized vaccine other than those listed above, they are responsible for being fully vaccinated by November 22,2021.

b. DoD civilian employees who are not fully vaccinated must comply with all DoD requirements for individuals who are not fully vaccinated, including those requirements related to masking, physical distancing, and travel. Regular COVID-I9 testing is not required prior to November 22,2021. On or after Novembet 22,2021, weekly COVID-19 testing is required for those DoD civilian employees who are not fully vaccinated, including those who have medical or religious exemptions. DoD civilian employees who telework or work remotely on a full-time basis are not subject to weekly testing, but must provide a negative result from a test performed within the pnor 72 hours for entry into a DoD facility.

c. DoD civilian employees are eligible to receive the COVID-I9 vaccine at any DoD vaccination site, including military medical treatment facilities. They may also opt to receive the COVID-I9 vaccine at locations other than DoD vaccination sites, such as retail stores, private medical practices, andlor local and State public health department sites.

d. New DoD civilian employees must be fully vaccinated by their entry on duty (sta$ date or November 22,2021, whichever is later.

The DoD or Office of the Secretary of Defense (OSD) Component head concerned may approve temporary exemptions in writing for up to 60 days after a DoD civilian employee's start date for urgent, mission-critical hiring needs in circumstances in which a DoD civilian employee could not have been fully vaccinated between the time the job opportunity announcement closes and the DoD civilian employee's start date. This authority may be delegated in writing to the DoD or OSD Component head's Principal Deputy (or equivalent) but no lower.

ll DoD Components must address the COVID-I9 vaccination requirement in job opportunity announcements and tentative and final offer letters. For hiring actions currently underway, DoD Components must issue revised tentative and final offer letters. Sample language can be found in reference (f).

s. DoD civilian employees are authorized official duty time to receive vaccination doses. For DoD civilian employees who are unable to receive a COVID-I9 vaccination within their duty hours, regular overtime rules are applicable.

f. DoD civilian employees are authorized administrative leave for purposes of taking a family member to get a vaccination and for themselves to recover from vaccination.

DoD civilian employees who experience an adverse reaction to a COVID-19 vaccination should be granted no more than2 workdays of administrative leave for recovery associated with a single COVID-19 vaccination dose. DoD civilian employees should use the time and attendance code for "physical frtness" to record administrative leave for COVID-19 vaccination recovery time that prevents the employee from working or for taking a family member to be vaccinated for COVID-

19. The type hour code is 6ÉLN" and the environmentallhazardlother code is "PF".

Non-appropriated fund employers should code administrative leave related to COVID-19 in a way that can be easily reported.

2. Verification of Vaccination

a. DoD civilian employees who have received a dose of a one-dose vaccine, or both doses of a two-dose vaccine, must provide proof of vaccination to their supervisors.

For purposes of the vaccination data submission and verification requirements, "supervisor" includes authorized human resources officials. Proof of vaccination may be submitted in hard copy or in an electronic format, and the proof may be a photocopy or photograph of the vaccination record, if it legibly displays the data points to be verified by supervisors. DoD civilian ernployees who are not fully vaccinated must provide proof of vaccination to their supervisors upon receipt of each required dose. Acceptable proof includes:

i. A copy of the record of immunization from a health care provider or pharmacy;

ii. A copy of the COVID-I9 Vaccination Record Card (CDC Form MLS- 3 1 98 1 3_r, published on Septemb er 3 , 2020);

iii. A copy of medical records documenting the vaccination;

iv. A copy of immunization records from a public health or State immunization information system; or

v. A copy of any other official documentation containing the data points required to be verified by the supervisor.

b. In addition to providing proof of vaccination to their supervisors, DoD civilian employees also will complete Section A of DD Form 3175 (Attachment 3). DoD civilian employees with access to milConnect (https://milconnect.dmdc.osd.miU) will complete the DD Form 3175 viamilConnect; otherwise use of a hard copy' is acceptable. DoD civilian employees who complete the DD Form 3175 via milConnect do not need to email or otherwise transmit a copy of the form to their supervisors. DoD civilian employees using a hard copy will provide the hard copy to their supervisor. DoD civilian employees are required to complete the DD Form 3175 even if they already completed the DD Form 3150 (Attachment 4).

c. Upon receiving proof of vaccination, a DoD civilian employee's supervisor will verify that the proof of vaccination provided contains the following data points:

1.

ii.

iii.

iv.

Type of vaccine administered;

Number of doses received;

Date(s) of administration; and Name of the health care professional(s) or clinic site(s) administering the vaccine(s).

d. In addition to verifying that a DoD civilian employee's proof of vaccination includes the required data points, supervisors also will complete Section B of DD Form 3 175 beginning on or about November 7,2021(or when activation of the form is completed for supervisor use). Supervisors with access to milConnect (https://milconnect.dmdc.osd.mil/) will complete the DD Form 3175 via milConnect using the DoD civilian employee's Employee Identification Number;

otherwise use of a hard copy is acceptable.

e. Supervisors will retain DoD civilian employees' proof of vaccination and DD Form 3175 (for those DoD civilian employees not using milConnect) in accordance with their DoD Component's recordkeeping requirements for DoD civilian employee medical records and the privacy requirements contained in Attachment 9.

Supervisors should not ask for copies of the DD Form 3175 from those employees who used milConnect to complete the form. Supervisors who receive completed copies of the DD Form 3175 from DoD civilian employees who completed the DD Form 3175 using milConnect shall not maintain the copy.

f. DoD civilian employees may not be required to use their own personal equipment for the purpose of submitting proof of vaccination or DD Form 3175. DoD civilian employees who submit proof of vaccination or the DD Form 3175 in an electronic format are encouraged to use encrypted email or password protected files with DoD SAFE fi le transfer (https ://safe. apps.mil/).

3. Enforcement of DoD Civilian Employee COVID-l9 Vaccination Requirement

a. DoD civilian employees who refuse to be vaccinated, or to provide proof of vaccination, are subject to disciplinary measures, up to and including removal from Federal service, unless the DoD civilian employee has received an exemption or the DoD civilian employee's timely request for an exemption is pending a decision. DoD

2 https://www.esd.whs.miUPortals/54lDocumentslDD/forms/dd/dd3 1 75.pdf

Components should generally follow the recommended guidelines in reference (g), subject to any applicable Component policy and collective bargaining agreements.

b. Progressive enforcement actions include, but are not limited, to

i. A 5 calendar-day period of counseling and education;

ii. A short suspension without pay, generally 14 calendar days or less, with an appropriate notice period. Senior Executive Service members may only be suspended for more than 14 calendar days;

iii. Removal from Federal service for failing to follow a direct order.

c. During the notice periods preceding adverse employment actions, DoD civilian employees generally should not be placed on administrative leave. DoD Components should require DoD civilian employees to continue to telework or report to the worksite and follow all mitigation measures applicable to not fully vaccinated DoD civilian employees when reporting to the worksite.

d. DoD Components will designate officials, at the appropriate organizational level, to handle the disciplinary process to promote consistent application of disciplinary measures. Such offrcials will decide each case with due regard to the facts and circumstances of that case. DoD Components may begin enforcement action as soon as November 22,2021, for DoD civilian employees who are not fully vaccinated and who do not have an exemption request approved or a timely request pending decision.

e. Supervisors should contact their servicing human resources and legal offices to discuss options available to address individual situations regarding enforcement of this requirement.

f. DoD Components are encouraged to identify an occupational health office, medical office, or other resource with which a DoD civilian employee may consult during the period of counseling and education.

4. Exemptions to DoD Civilian Employee COVID-l9 Vaccination Requirement:

DoD civilian employees may request an exemption on the basis of a medical condition or circumstance or a sincerely held religious belief, practice or observance. Because all DoD civilian employees must now be vaccinated against COVID-19 as a condition of employment, exemptions will be granted in limited circumstances and only where legally required. The information collected must be handled in accordance with the privacy requirements in Attachment 9.

a. Decision Authority. In establishing exemption processes, the Secretaries of Military Departments and the Director of Administration and Management for all other DoD Components will ensure that the management official(s) who are designated to make decisions conceming requests for exernption from the COVID-I9 vaccination requirement make such decisions in coordination with the organization's servicing legal office and are at an appropriate level within the organization to consider the impact, if any, of the volume of requests and to promote similar cases being handled in a consistent manner. Such officials will decide each case with due regard to the facts and circumstances of that case.

b. Employee Notice. DoD Components will inform DoD civilian employees how to make a request for an exemption and notify them that requests must be submitted no later than November 8,2021, absent extenuating circumstances, to be considered timely.

c. Employee Requests. To make a request for exemption from vaccination, DoD civilian employees must provide an official statement which describes the medical or religious reason the employee objects to vaccination against COVID-19. Generally, such requests should be submitted in writing. DoD civilian employees may use DD Form 3176 (Attachment 5) or DD Form 3177 (Attachment 6) to submit their request.

DoD civilian employees who make oral requests may be provided a sample written request format andlor be interviewed to develop the basis for the request. While the use of the DD Form 3176 and DD Form 3T77 is optional for DoD civilian employees, when DoD civilian employees make a request, they must provide the following information.

Medical.

o A description of the medical condition or circumstance that is the basis for the request for a medical exemption from the COVID-19 vaccination requirement;

o An explanation of why the medical condition or circumstance prevents the employee from being safely vaccinated against COVID-19;

o If it is a temporary medical condition or circumstarrce, a statement conceming when it will no longer be a medical necessity to delay vaccination against COVID-I9; and

. Any additional information, to include medical documentation that addresses the employee's particular medical condition or circumstance, which may be helpful in resolving the employee's request for a medical exemption from the COVID-19 vaccination requirement.

Religious.

o A description of the religious belief, practice, or observance that is the basis for the request for a religious exemption from the COVID-19 vaccination requirement;

o A description of when and how the DoD civilian employee came to hold the religious belief or observe the religious practice;

o A description of how the DoD civilian employee has demonstrated the religious belief or observed the religious practice in the past;

o An explanation of how the COVID-l9 vaccine conflicts with the religious belief, practice, or observance;

o A statement concerning whether the DoD civilian ernployee has previously raised an objection to a vaccination, medical treatment, or a medicine based on a religious belief or practice. If so, a description of the circumstances, timing, and resolution of the matter; and Any additional information that may be helpful in resolving the DoD civilian employee's request for a religious exemption from the COVID-l9 vaccination requirement.

d. Minimum Requirements for Exemption Procedures. The Secretaries of Military Departments and the Director of Administration and Management for all other DoD Components will ensure that exemption procedures require the following measures.

Development of a written factual record that includes the following:

o The basis for the claim;

o The nature of the DoD civilian employee's job responsibilities; and o The reasonably foreseeable effects on the agency's operations, including protecting other agency employees and the public from COVID-19, if the civilian employee remains unvaccinated.

Designation of the DoD civilian employee's supervisor for completing Section B of the DoD civilian employee's DD Form 3775, as the proper recipient for a DoD civilian employee's request for exemption. For purposes of exemption request procedures, "supervisor" includes authorized human resources officials. Upon receipt, the supervisor will update the DD Form 3175 to indicate a request for exemption determination is pending and forward the request to the office supporting the designated decision maker.

A process for the decision maker to obtain any reasonably necessary additional information (for example, medical documentation, an interview of the DoD civilian employee, or a supervisor statement) and to consult with, as appropriate, subject matter experts within DoD such as occupational health personnel, public health personnel, equal employment opportunity advisors, chaplains, and human resources personnel.

A written determination, including the reason(s) for that determination, by the decision maker. In cases where the exemption is temporary or denied, the determination must specify a date by which the DoD civilian employee must be fully vaccinated against COVID-19. In specifying that date, DoD civilian employees must be given a minimum period of 14 days to receive their first (or only) dose of a COVID-19 vaccine.

Provision of the written determination to the DoD civilian ernployee's supervisor, who, in turn, provides the DoD civilian employee with a copy of the written determination, updates the DD Form 3175, and informs the DoD civilian employee of next steps.

e. AdditionalGuidance.

Requests for medical exemption will be treated as medical records to be maintained separately from other personnel files. Both medical and religious exemption requests will be maintained in accordance with the privacy requirements at Attachment 9.

1.

l1

111.

IV

ii. A DoD civilian employee's failure to submit a timely request for exemption is not a basis to deny a request but may be relevant in evaluating the request.

iii. Discipline for failure to meet the COVID-19 vaccination requirement will not be initiated against a DoD civilian employee while a timely request for a medical or religious exemption from the COVID-l9 vaccination requirement is pending determination. If a DoD civilian employee submits a request after discipline is initiated, disciplinary measures may be held in abeyance where appropriate.

iv. DoD civilian employees who are not fully vaccinated but who have a pending request for exemption from vaccination are required to comply with any mitigation measures that are applicable to all DoD civilian employees in the worksite who are not fully vaccinated (for example, screening testing (Attachment 7), masking, and physical distancing). Requests for reasonable accommodation related to those mitigation measures may be analyzed separately from requests for exemption from vaccination.

v. A DoD civilian employee who receives an exemption from the vaccination requirement may, because of the exemption, be unable to perform the duties and responsibilities of the position without a change in working conditions.

Such matters will be referred to the reasonable accommodation process.

vi. Requests for exemption from candidates for employment will be handled consistent with the provisions in this attachment, except for those in paragraph 4.b.

vii. Unless responsibility is otherwise established in a written support agreement, the Combatant Command Support Agent identified in reference (h) is responsible for administration of exemption processes applicable to DoD employees assigned, detailed, or otherwise deployed to a Combatant Command area of responsibility.

ATTACHMENT 2

Requirements for DoD Contractor Personnel, Official Onsite Visitors, and Others Seeking

Access to Facilities

1. DoD Contractor Personnel

a. For DoD contractor personnel, the DoD civilian vaccination deadline of November 22,2021, does not apply. Vaccination requirements for DoD contractor personnel will be in accordance with reference (i), as implemented by reference (j), as directed under Executive Order 14042 (reference (k)).

b. DoD contractor personnel will complete the DD Form 3150, "Contractor and Visitor Certification of Vaccination" (Attachment 4),maintain a currsnt completed DD Form 3150, and show it to authorized DoD personnel upon request. Failure to complete the DD Form 3150 may result in denying DoD contractor personnel access to the DoD facility to which access is sought.

c. DoD contractor personnel who are not fully vaccinated against COVID-19 because they are not performing under a covered contract that requires COVID-19 vaccination, due to a legally required accommodation, or who decline to attest to their COVID-19 vaccination status will be subject to COVID-19 screening testing at least weekly as set forth in this guidance (Attachment 7). DoD contractor personnel who refuse required screening testing will be denied access to DoD facilities.

d. In accordance with applicable contracts, DoD contractor personnel may be offered, but are not required to receive, COVID-19 vaccines at their DoD worksites.

2. Official Onsite Visitors

a. Official onsite visitors will complete DD Form 3150, "Contractor and Visitor Certification of Vaccination"3 (Attachment 4); and maintain a current completed DD Form 3150 and show it to authorized DoD personnel, upon request. Failure to complete the DD Form 3150 may result in denial of an official onsite visitor's access to the DoD facility to which access is sought.

b. Official visitors who are not fully vaccinated against COVID-I9, or who decline to volunteer their COVID-l9 vaccination status, must show an electronic or paper copy of negative results from an FDA-authonzed or approved COVID-l9 test administered no earlier than72 hours prior to their visit. If an official visitor is unable to show a negative COVID-19 test result, the visitor may be provided onsite self-testing, if available, or will be denied access to the DoD facilities to which access is sought.

Service members who are not on active duty at the time of their official visit are subject to the requirements in this paragraph.

3 https://www.esd.whs.miUPortals/54/Documents/DD/forms/dd/dd3 I 50.pdf

c. OfEcial visitors will follow applicable policies and procedures of both DoD and the Department or Agency they are visiting, if different from DoD.

3. Others Seeking Access to Facilities

Individuals other than official visitors seeking access to facilities located on DoD installations, but operated by other Federal departments and agencies, will follow the policies and procedures of that other department or agency.

t2

ATTACHMENT 3

DD Form 3175 - "DoD Civilian Employee Certification of Vaccination" CUI (when filled in)

DoD CIVILIAN EMPLOYEE CERTIFICATIoN OF VACCINATION

PRIVACY ACT STATEMENT

Authority: Pursuant to 5 U.S.C. chapters 'l l and 79, and ìn d¡scharg¡ng the functions directed under Executive Order 14043, Requiring Coronavirus Disease 20l9VaccinationforFederal Êmployees(Sept.9.2021),DoDisauthorizedtoællectthisinformation. Additional authoritiesforthesystemsofrecords associated with this collection of infomation also include: E.O. 13991, Protect¡ng the Federal Workforce and Requiring l4ask-Wearing: E.O. 12196, Occupat¡onal Safetyand Health ProgramforFederal Employees; '10 U.S-C. 113, 10 U.S-C. 136. 10 U.S.C.7013, 10U.S.C.8013, 10 U.S.C.9013, 10 U.S.C.2672:DoD Directive5525.21;andDoDlnst¡uct¡on6200.03. Provid¡ngthisinformat¡onismandatory,andDoDisauthorizedtoimposepenaltiesforfa¡luretoprovidethe ¡nformation pußuant to applicable Federal personnel laws and regulât¡ons.

Princ¡pal Purpose: This ¡nfomation is be¡ng collected and ma¡ntained to ¡mplement Coronavirus Disease 2019 (COVID-19) ivorkplace safety plans, and ensure thé safêty and protection of the DoD worKorce. workplace, and other DoD facil¡ties and environments, consistent w¡$ the above-referanced author¡ties.

the COVID-19 Workplace Sâfety: Agency N4odel Safety Principles establ¡shed by thê Safer Federal Workforce Task Force. and guidance from the Centers for Disease Control and Prevent¡on and the Occupational Safety and Health Administration.

Rout¡ne Use(s): While thê information requested on th¡s form is intended to be used primarily for intêrnal purposes, in certa¡n circumstancês ¡t may be necessary to d¡sclose th¡s information extemally, for example to d¡sclose ¡nfomation to: a person, organiät¡on or governmental entity as necessry and relevant to notify them of, respond to, or guard aga¡nst a publ¡c health êmergency, or other similar cr¡s¡s. including to comply rvith laws govern¡ng the reporting of commun¡cable disease or other laws concerning heâlth and sâfêty ¡n the work env¡ronment; adjud¡cat¡ve bod¡es (e.9., the Mer¡t System Pþtect¡on Board), arb¡tratoß. and hearing exam¡ners to the extent necessary to cary out the¡r authorized duties regarding Federal employment; contractors, grantees, experts.

consultanls, students. and othsrs as necessary to perform their duties for the Federal govsmment; or agenc¡es. courts, and persons as nècêssary and relevant ¡n thê course of litigal¡on, and as necessary and in accordance lvith requirements for law enforcement: or to a person authorized to act on your behalf.

A complete list of rout¡ne uses may be found in the applicable System of Records Not¡ce (SORN) assoc¡âted '¡r¡th the collection of this infomation as follorvs:

For most Fedêral civilian employees: OPMi GOW-1 0. Employee Medical File System Records. 75 Fed. Reg. 35099 (Jun. 21,2010I amended 80 Fed. Reg.

74815(Nov.30,2015). ForFederalc¡vilianemployeesnotcoveredbyOPfitVGOW-'|0: DPR39DoD,DoDPèrsonnelAccountabilityandAssessmentSystemof Records, 85 Fed. Reg. 17047 (Mar.26, 2020) (also available at https://dpcld.defense.govi Portals/49/Documents/Privacy/SORNs/OSÐJS/DPR-39-DoD.pdf).

Consequences of Fallure 10 Provide lnlormat¡on: Providing this information is mandatory. Unless granted an exemption, all covered Federal civilian employeesarerequ¡redtobevaccinatedagainstCOV|D-'19. Employeesarerequiredtoprov¡dedocumentationconcern¡ngtheirvacc¡nat¡onstatustotheir employing DoD Component. Fa¡lure to provide this infomation may subject you to d¡sciplinary aclion, including and up to removal from Federal seruice.

INSTRUCTIONS: Section A of this form should be compieted by DoD civ¡l¡an employeês only. Section B of this form should ba completed by the DoD civìlian employee s supervisor (or auhor¡zed human rêsources off¡cial). This fom should be completed by DoD civil¡an employees only. Seru¡ce members and employees of DoD contractors should not complete this form.

SECTION A. To be completed þy DoD civil¡an employees.

1. CIVILIAN EMPLOYEE NAME (Las¿ Fißt.

^41)i

2. CIVILIAN EMPLOYEE DoD ID NUMBER:

3. PLEASE CHECK ALL THAT COINCIDES WTH YOUR COVID-19 VACCINATION STATUS:

fl S.a. I am fully vaccinated.

lndrvduãls are cons¡dered fully vacc¡nated" two deeks after completing the second dose of a tvrodose COVID-1 9 vacc¡ne or ¡do weeks after receiving a single dose of a one-dose vacc¡ne. Accepted COVID-19 vaccines are those which have received a l¡cense or emergency use âuthorization from the U.S. Food and Ðrug Adm¡n¡strat¡on and those COVID-'19 vaccines on the World Health Organ¡zation Emergêncy Use Listing.

''Fully vaccinated" also jncludes circumstances ¡n which the ind¡vidual was a partic¡pant in a U.S- site clinical lrial and has received all recommended doses.

fl S.U. I have rece¡ved one or more doses, but I am not yet cons¡dered fully vaccinated (in amrdance w¡th the definitiÕn of fully vaccinated above).LJ

I I S.c. t have submitted proof of vaccination to my supervrsor.

Proof of vaccination includes a copy of the record of immun¡zation from a health care provider or pharmacy, a copy of the COVID-19 Vaccination Record Card. a copy of medical ræords document¡ng the vaccinat¡on, a copy of immuniætion records from a public health or state immun¡zat¡on ¡nformat¡on system. or a copy of any other offcial documentation. Employees may provide a digital copy of such records, ¡ncluding. for example, a digital photograph. scanned ¡mage. or PDF ot such a record that is clear and legible.

1--] S.¿. r havê not received anv vaccination doses.ll fl S.e. I have submitted a request for an exempt¡on from vaccination and a dec¡sion is still pending.L] t I a.i. t have an approved exemption from vaccinat¡on.

II

CUI (when filled in) Controlled by: OUSD(P&R) Page 1 of 2 Conlrolled bv ASD(HA) CUI Category HLTH. PRVCY, OPSEC LDC: DL(DoD Only) POC. osd.oentaoon ousd-o-r.mtìx fomsrarnìatl nìil

DD FORM 3175,OCT 2021

CUI (when filled in!

CUI (when filled in)

4. EMPLOYEE VACCINE INFORMATION (Employæs checking block 3.a. should skip block 4 and go to block 5)', 4.b. DATE OF FIRST DOSE:

4.c. DATE OF SECOND OQSE (if two4ose vaccine)

4.a. VACCINE MANUFACTURER(S) OR VACCINE PRODUCT NAME(S):

l l Pfizer-BioNTech/Comimaty n Moderna n AsÍaZeneæ/Oxford n Johnson and Johnson (J&JyJanssen

Tl Novavax

Other U.S. Food and Drug Administrat¡on l¡cênæd or author¡zed, World Health Organ¡zation Emergency Uæ listed vaccine or U.S. site cliniæl trial vaccine (provide name):

il 4,d. DATE FULLY VACCINATED:

5. CERTIFICATION/KNOWLEDGE OF POSSIBLE ACTIONS FOR FALSE STATEMENTS

I certify that the information I have provided on this form and the proof of vaccination documentation I have submitted is true and conect.

I understand that a knolving and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. '1001 )- | understand that making a false statement on th¡s fom could result in additiorial administrative action ¡ncluding an adverse personnel action up to and ¡nclud¡ng rsmova¡ from my pos¡tion.

u

6. CIVILIAN EMPLOYEE SIGNATURE:

7. DATE:

SECTION B. To be completed by the supervlsor of the DoD clvillan employee completlng sectlon A (or an authorlzed humûn resources offfclall

8. SUPERVISOR PROOF OF VACCINATION REVIEW

I e.a. Crcot ot vacc¡nat¡on not reæ¡ved.

! 8.U. Prool of uaccination received and under rev¡ew.

! 8.c. Proof of vacc¡nation r6cê¡vêd and reviewed.

9. STATUS OF VACCINATION. EXEMPTION REVIEW

n 9.a. Exemption request rece¡ved and pending dispositim.

n 9.b. Exemption request received end approved.

n 9.c. Exemption request rÊceivod and dêni€d.

n 9.d. Exemption request not ræived-

10. SUPERVISOR /AUTHORIZED HR OFFICIAL NAfilE llast, F¡rst, Ml)i 11. SUPERVISOR / AUÎHORIZED HR OFFICIAL DoD ID NTJMBÊR:

12. SUPERVISOR / AUTHORIZED HR OFFICIAL SIGNATURE:

13. DATE:

PREVIOUS EDITION IS OBSOLETE.

l4

CONTRACTOR PERSONNEL AND VISITOR CERTIFICATION OF VACCINATION OMB No 0704-¿613 ExFiâtioî: n220228

AGENCY DISCLOSURE NOIICE

The public repdting burden fd th¡s cdlect¡m of ¡nfümation is est¡mated to average 2 minutes per response, ¡nclud¡ng the time fd review¡ng ¡nstruct¡os, searching ex¡sting data sdrces, gathering and mainta¡ning the data needed, and cmpleting and review¡ng the collect¡m of ¡nformat¡on. Send cdnments regarding th¡s burden est¡mate or any other aspect ofthis collectin of information, including suggest¡trs for reduc¡ng the burden, to the Oepartment of Oefense, Washingtorì Headquarters Services, at whs.mc-alex.esd.mbx.d+dod-infomat¡oncdlecti$s@ma¡l.mil. Respondents should be aware that notw¡thstanding any cther prwis¡d of law, no person shâll be subject to any penalty for fail¡ng to comply with a collect¡m of infdmat¡m ¡f it dæs nd display a curently val¡d OMB cfrtrol number.

PRIVACY ACTSTATEMENT

Authorlty: DoD is authorized to cdlect the infmation tr th¡s form pursuant to Executive Order (E.O.) 14042, Ensur¡ng Adequate COVID Safety Protocds for Federal Contractorsi E.O. 13991, Prdect¡ng the Federal Workforce and Requ¡ring Mask-Wearing; and E.O. 12196, Occupational Safety and Health Program fd Federal Ernplc'yees; aswell as 10U.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. chapterT9.andDoD lnstruction 6200.03.

Princ¡pal Purposs: Th¡s infomatim is be¡ng cdlected to ¡mplement Cqsavirus Disease 2019 (COMÞ19) workplace safety plans, ¡nc¡uding DoD's COMÞ19 test¡ng programs, and to ensure the safety and protect¡o ofthe DoD wükfrce. wdkplace, and other DoD fac¡l¡t¡es and environments, ctrs¡stent w¡th the abwe-referenced authdities. the COVID-'19 Wtrkplace Safety: Agency Model Safety Principles establ¡shed by the Safer Federal WüKorce Task Force, and guidance frqn the Centers for D¡sease Contrd and Prevent¡on and the Occupational Safety and Hea¡th Administrat¡s.

Routlne Use(s): Wh¡le the ¡nfmation requested on lhis form is intended to be used pr¡marily for internal purposes, in cerlain c¡rcumstances ¡l may be necessary to d¡sclose th¡s inftrmatifr externally, foa example to disclose information to: a person, oaganizat¡on, or gor'ernmental entity as necessary and relevant to not¡ry them ol resptrd to, or guard against a public health emergency or other s¡m¡lar crisis, includ¡ng to comply w¡th laws govem¡ng the reptrt¡ng of cmmunicable disease or other laws conceming health and safety ¡n the work env¡ronment; adiud¡cative or admin¡strat¡ve bodies or oficials when the recüds are relevant and necessary to an adjud¡cative or adm¡nistrat¡ve proceed¡ng: contractors, grantees, experts, consultants, students. and otheß as necessary to perform their dut¡es for the Federal gor'ernment; agencies, courts, and persons as necessary and relevant ¡n the course of ¡itigation, and as necessary and in accordance with requ¡rements ftr law enfscementi or to a person authorized to act on your behalf. A complete list ofroutine uses may be found in the appl¡cable System of Records Not¡ce (SORN) assæ¡ated w¡th the collect¡orì ofth¡s information frorn corìtraclor personnel and DoD visitors: DPR 39 DoD, DoD Persmnel Accountab¡l¡tyand Assessment System ofRecords, SS Fed. Reg. 17047 (Mar. 26,2020\ (also available al https://dpcld.defense.gov/Portals/49/ Oocuments/Privacy/SO R Ns/OSDJS/DPR-39-DoD.pdf).

Consoquoncos of Failure to Provids lnformation: Prov¡ding this ¡nfqmat¡s ¡s vduntary. Hwever. if yd fail to prw¡de this ¡nformat¡d, you w¡ll be treated as not fully vaccinated for purp6es of implement¡ng safety measures, ¡ncluding subject to COVIÞ19 screening testing and/or denied access to DoD facilit¡es.

Failure to prwide such informat¡on may also h¡nder DoD's ability to implement COV|Dl9 wdkplâce safety plans, thereby increasing the health d safety risk to DoDafiiliated pers6ìnel and DoD fac¡l¡ties.

INSTRUCTIONS: Th¡s form should be cornpleted by DoD contractq persmnel and official visittrs in accordance w¡th current DoD Foree Health Prctectiofl Guidance. DoO civilian employees should not cornplete th¡s fom.

l. NAME llasf, Fr¿s¿ [tt: 2. DoD lD NUMBER:

3. PLEASE CHECK THE BOX BELOW THAT COINCIDES WTH YOUR COVID-I9 VACCINATION STATUS :

f_-] I am tully vaccinated.tJ lndividuals are cons¡dered "fully vacc¡nated' two weeks afrer completing the second dose of a twcdose COVIÈ19 vacc¡ne or two weeks after rece¡ving a single d6e of a one-dGe vaccine. Accepted COV|Dl9 vaccines are those which have rece¡ved a l¡cense or emergency use authtrizat¡on fim the U.S. Fæd and Drug Admin¡stratid and those COMD19 vaccines d the World Health Organ¡zat¡on Emergency Use L¡st¡ng.

'Fully vaccinated" also ¡ncludes circumstances in wh¡ch the individual was a partic¡pånt ¡n a U.S. site cl¡nical trial and has received all recmmended dæes.

f-] lamnotyetfullyvacc¡nated. lrece¡vedonlyonedoseofanacceptedtwcdoseCOV|D-'lgvaccine,dlrece¡vedmyfnal doseofanacceptedCOV|D-19 vaccine less than two weeks ago.

f_l I have not been vaccinated.LI f_-] I decl¡ne to resoondLI lndividuâls who chGe not to cffiplete the form will be assumed to be not tully vaccinated for pu rposes of applicat¡on of the safety protocols. lf you are not vaccinated due to medical cr religious reasons, please check either "l have not been vaccinâted" or "l decl¡ne to respond." Note that ifyou have already received one d6e of a wccine, but are not yet tully vaccinated, or if you rece¡ved y@r fna¡ dose less than two weeks ago, then you w¡ll be keated as not fully vaccinated until you are at least two weeks past ydr fnal dose and resubmit ydr vacc¡nat¡o ¡nfqmat¡ú.

f_-] lcertifothattheinfomationprovidedinthisfm¡saccurateandtruetothebestofmyknowledge.

L___l lunderstandthataknryingandw¡llful falsestatementoth¡sfmcanbepunishedbyinedimprismmentorboth(18U.S.C. 1001). Checking"l declineto respond" does not constitute a false statement.

4. OATE (YYYY1úMDD) 5. SIGNATURE lFul wame)

ATTACHMENT 4

DD Form 3150 - "Contractor Personnel and Visitor Certification of Vaccination"

CUI (when filled in) cur(whenrinedin) 3::ili::il;i3;,ffiit CUI Catègory: HLTH: PRVCY; OPSEC

LDC: DL(DoD Only) POC: osd.Þätaoon.ousdÞr.mbx.frms@ma¡l.mil

REQUEST FOR A MEDICAL EXEMPTION OR DELAY

TO THE COVID.19 VACCINATION REQUIREMENT

OMB No. 0704461 I Exp.20220430 souræs, gaths¡ng and maìntain¡ng the data needed, and completing ild reviewing the collæt¡on of¡nbmation. Send comments .egarding th¡s búrdff est¡matê or añy other asped of this ællection of¡nbmat¡on. including egged¡o¡s for reducÌng the burden, to the Department ofDefense, \ lash¡ngton Headquartqs Serices, at whs.mc"alex.esd.mbx.dédo+ coll€ction of infqmatid if it dæs not display a currenüy valid OMB co.¡trol numbêr.

PRIVACY ACT STATE¡I ENT

D¡seaæ æ19 Vaccination fú Fêdênl Employees; E.O. I 31 63, lncreas¡ng the Opportun¡ties for lndviduals witì Disaul¡t¡es to be Employed in the Federal Government; E.O. 1 3164, Requ¡íng FedeEI AgÐciesto Establish Præeduresto Facilitatethe Provis¡ú ofReasmableAccommodat¡oni 29 CFR l614.2æ. Rehab¡l¡tat¡on Ach DoD Diæctive 1020.1, Nondsr¡m¡nation on tho Basis of Hand€p in Programs ùd Äctivitiês Asisted or Conductêd by thê Department of Dêfêhse; as well as l0 U.S.C. 113, 10 U.S.C. 136, 10 U.S.C. 7013 10 U.S.C. 8013, l0 U.S.C.9013, 10 U.S.C. 267a 5 U.S.C. chaptq 79. and DoD lnstruct¡on 6200.6.

PrlnclpalPurpose: Theinfomat¡ononthisfurm¡sbe¡ngcollætêdethatDoDmaydetêminewh€thertoghntyourrêqu6tforamedical êxemptionfroñtheCOV|Dl9Ecc¡nation requ¡rfrst for fedeEl omployæs, pußlant to Exêcutive Ords 14043 and ¡n furthêEnco of COVlD l9 wdkplace sfety plans.

Roullne Use(s): Wh¡lê thê inbrmalioñ réquêsted on th¡s form is inte¡dêd !o bo usêd pr¡mar¡ly for ¡htêrnal purposes, ¡n ceÉain c¡rdmstancos it may bê nêcossary to disclos6 this inturmation: DoD 0002 D€bnsê R€aenabl6 Accommodations and Asìstivê Têchnology Rê@rds. 86 F6d. R€9. 38692 (July. 22. 2010) (ava¡lablê at l[0srqw,goylnfg,ggtl contenuokqlFR-2021-07.22pül2021.1 560l.pdD.

ConsequencesofFalluretoProvldelnlomalion: Prdidngü¡sinfomat¡onisvoluntaryandusêofthisfomisoptiùal.Fa¡luretoprovidêthsinformationrêquêst€donth¡sfom may¡mpactDoD'sab¡litytoevaluateoracluponarequesttqamedica¡ êxemptionfromtheCOVlùl9vaccinationr€quiromont. Any¡nteñtionalm¡sr€preser¡tationtothoFederal Govqnmorit may rêsult ¡n l6gal consêquenés, iñcludng temination or remwal from Fêderal S€ruiæ.

lnstruct¡ons: Part '1 is to be completed by DoD civilian employees. Part 2 is to be cmpleted by a l¡censed health care provider. Prdide narative responses where applicable (Blocks &10, 15-17). lf add¡tional space is needed. præeed on the appropriate cont¡nuat¡on block (Blæk 11 or 20) byannotat¡ngthe Sectim and Line number and cont¡nue your narrat¡ve response. S¡gning this form constìtutes a declaration that the informat¡m you prwide is. to the best ofyour knowledge and ab¡lity, true and corect. Any ¡ntentional m¡srepresentation tothe Federal Gdemment may result in legal cdsequences, including removal fim Federal Service

PART I. TO BE COMPLETED BY THE DOD CIVILIAN EMPLOYEE

l. Employee Name (L€s¿ Firsl" M¡ddle ln¡tia| 2. DoD lO Number

3. OfRcê Ðmbol 4. Datâ of Rsquost (YYYYMMDD)

5. Position/Tltle 6. Srpervlsor Nms 7. Srpervlsor Phon6 Numb€r

8. Please provids a dsscription of the msd¡cal condit¡on or c¡rcumstance that is the basis for the requ€st for a medical exemption trom the COvl D-l I vacclnatlon rsqulrsmont.

9. Please provide an explanation of why the medlcal condltlon or clrcumstance prevents you ñom belng vacclnatêd.

10. Pleass provlds ily addltlonal lnformatlon, that addresses your partlcular medlcal condltlon or clrcumstanco, wñlch may bs helpful ln rssolvlng your roquost for a mêdical exempt¡on or dslay from the COMD-'I I vacc¡nat¡on requ¡remant. lf you havs m€dical documsntation (in add¡l¡on to Pårt 2 of thls Form) that addresses your partlcular medlcal conditlon or clrcumstance you may submlt the documentatlon to your supervisor along with thls form.

ATTACHMENT 5

DD Form 3176 - "Request for a Medical Exemption or Delay to the COVID-l9 Vaccination Requirementt' CUI (when filled in)

3176,OCf 2021 GUI (when filled in) CUI Calogory: HLTH.

LDC: DL(DoD Only)

PREVIOUS EDITION IS OBSOLETE

t6

POC:

OPSEC

CUI (Yvhen filled in)

GUI {when filled in)

11 - Contlnuatlon

I declare to the best of my knowledge and abil¡ty that the foregoing ¡s true and ctrect.

12. Datø (YYYYMMDD) I 3. S¡gnature

PART 2. COMPLETED BY EMPLOYEE'S HEALTH CARE PROVIDER

14. Employ€6 Nams

MEDICAL CERTIFICATION FOR COVID-,I9 VACCINE EXEMPTION OR DELAY

The Department ofDefense requires its employees tobefullyvacc¡nated against COVIÞ19, pursuant to Executlve Order ofthe President ofthe United Slates.

As ind¡cated in Part 1, the indiv¡dual named abo/e ¡s seeking a medical exemption to the requirement for COVID-l 9 vacc¡natiorì q a delay because of a temporary condition or medical c¡rcumstance. Please complete this fm to ass¡st the Department in its rev¡ew præess.

Pleâse provide at lgast the follow¡ng infümat¡ff, where applicable, and use the continuation block as needed:

Dear Health Care Provider:

15. Plêass ¡dentify ily contra¡nd¡cation(s) or precaution(s) for COVID-19 yacc¡nation lhat ar€ appllcablo to the ¡ndividual, and for sach contra¡nd¡cation or precarf ion, ¡ndicato:

(a) whether it is recogn¡zed by the U.S. Centers ftr Disease Control and Prevent¡d pursuant to ¡ts guidance; and

(b) whethet it is l¡sted in the package ¡nsert s Emergency Use Author¡zation fact sheet for each ofthe COVlDl9 vaccines authd¡zed or approved for use in the Un¡ted States.

16. Please provlde a statement detalllng howthe lndlvldual's condlt¡on and medlcal clrcumstances are such that COVIO-19 vacclnatlon is not consld€rsd safe. Pl€ase sxplaln tho speclflc nature of the modlcal condltlon or clrcumstilce that contnlndlcatss lmmunlzation wlth a COVID-19 wccins or might increasê tho risk for a sêrious adyerss reaction.

17. Please provide ily olher med¡cal ¡nfomation that wuld l¡m¡t the employ€e from rece¡ving any COVIo-19 vaccine.

18. The cond¡t¡on d€scr¡b€d abovs ¡s:

f] temporary

.l Long-Terrn/Permanent

'19. lfthe employee ls seeklng a delay due to a temporary medlcal condltlon or clrcumstance, please lndlcate when the employee ìr,ould bs abls to safely receive a COVI D-i9 vacclnatlon - provlde detalls lf llm¡ted to spoclflc COVID-19 vacclns{s) or typsls} of COVID-19 Ecclne.

20. conflnuaflon

21. Hsalth Caro Provider Namo/Title

22. Date (YYYYMMDD) 23. Madical Provider S¡gnatur€ l7

ATTACHMENT 6

DD Form 3177 - íRequest for a Religious Exemption to the COVID-l9 Vaccination

Requirement" CUI (when filled in)

CUI (when filled in) Cor¡lrollêdby:OUSD(P&R) Pago'l of2 CUI Cal6gory: HLTH. PRVCY, OPSEC LDC: DL(DoD O¡ly) POC: dodhra.mc-ålox.dhr+hq.mbx.foms@mall.mll

REQUEST FOR A RELIGIOUS EXEMPTION TO THE COVID.19 VACGINATION REQUIREMENT

PRIVACY ACT STATETI Ei¡T Authority: DoDìsauthodzedtocollectthe¡nfdmaliononür¡sformpt¡rsuanttroExecutiveOrdêr(Ê.O.)14043,Requ¡ringCoronavirusDiæase2019Vaccinat¡onforFedeÞl Employes;42U.S.C. Chapte¡21, SubchaÉerVlt 42 U.S.C. Chapter2lB; aswell as 10 U.S.C.113, 10U.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. chaptor 79. and DoD lnstructiø 6200.03.

Princlpal Purpose: The inbmation on his form is be¡ng collæted s that DoO may ddemine whether to gmnt your requæt br a relig¡ous exffiption from fie COV|Dl9 vaæination rêqu¡rmstbrfedeÞl êmployæs.pursuantto&êcutivôOrdâ14043and¡nfurthêEncêofCOV|Èlgwùkplaæef€Êyplans. Cds¡st6ntw¡thûìêRêligiousFrêêdomRsgorationA.t will submit to DoD suppot¡ng informatid about thêir rêlig¡ous bel¡sß or pncticês in ord€r fÞr OoD to waluat€ ths êxmption requêst.

inbrmation sxternalV. For example to d¡sclo$ infumation to: a pêren. organ¡ãt¡on, or gowrnmental entity as necessary and rdrant to notit them oi respond to, or guard against a ênv¡ronmênt; aCudì@t¡ve or administEtive bod¡es û ofrcials when the records are Élevdt and ne6ssily to an adjudi€tive or adminidrativè procæd¡ng; contEctors, grantees, expeds, consultanls, students, and otheF as nec6sary to pêrbrm thêir dutiês for thê Fêdêñ¡ government; agñciès, @urts.