Immunized Traveler Waiver Request Form - 23 Apr 2021.pdf

PHNSY&IMF COVID-19

IMMUNIZED TRAVELER WAIVER REQUEST

For Contractors and Subcontractors

Section 1 ‐ Government to complete

REQUESTING ORGANIZATION JOB TITLE SUSPENSE FOR DECISION

PHNSY&IMF POC SY ORGANIZATION/CODE CONTACT NUMBER

Section 2 – Contractor to complete

Ship (If Applicable)

Description

Work Scope

Specific Worksite/ Location to perform work (unclassified)

Dates (includes all on‐ site dates)

Origin of Travel

Layover Locations/ Stops during travel to

PHNSY

Justification/ Reason for Waiver

Traveler Information:

Refer to Appendix B for list of Immunized Travelers.

Section 3 ‐ Mitigations Taken or Being Taken to Lower Risk

Traveler(s) will meet State of Hawaii protocols and abide by HPCON measures while interacting with Shipyard personnel.

‐ Will follow PPE requirements and will wear masks when performing official duties on behalf of the DoD and the DoN from any location including outdoor spaces.

‐ Will conduct daily self‐assessment prior to accessing JBPHH and will remain in quarters if experiencing any illness symptoms.

‐ Will comply with any additional COVID‐19 mitigation requirements of (fill in hull number)

Immunized Traveler

For Contractors and Subcontractors

RECOMMENDATIONS:

PHNSY&IMF POC

☐Yes

☐No X

PHNSY&IMF POC

Contractor/Requesting Organization The individual(s) listed in Appendix B understand(s) PHNSY & IMF’s mitigations to be taken in Section 3 and “immunized traveler” requirement in Appendix A.

☐Yes

☐No X

Contractor/Requesting Org

APPROVALS:

PHNSY&IMF Code 1130 or 106 ☐Yes

☐No X

Code 1130 or 106

For Contractors and Subcontractors

APPENDIX A

1. Purpose:

To outline the Pearl Harbor Naval Shipyard & Intermediate Maintenance Facility (PHNSY&IMF) COVID-19 Immunized Traveler requirements to facilitate the waiver from the 10-day restriction of entering DOD workplace. .

2. Requirement:

(a) Immunized Traveler waivers may be provided to those who meet all the requirements listed below.

(i) Traveler is immunized;

(a) A traveler is considered immunized if he/she has received all required doses for the specific COVID-19 vaccine AND at least 14 days have passed since the final vaccine dose BEFORE the start of the self-quarantine/restriction period. Vaccine Doses:

Pfizer – 2 doses, Moderna – 2 doses, Johnson & Johnson – 1 dose. Please submit a complete copy or provide access to a complete copy of the traveler’s CDC COVID- 19 Vaccination Record Card or, if the card is lost, another form of administratively acceptable evidence of immunization (healthcare provider documentation).

(ii) Travel originated from Alaska, CONUS, or inter-island;

(iii) Immunized Traveler meets the Pre-Travel testing requirements for the State of Hawaii Safe

Travels Program AND the State of Hawaii has exempted the Immunized Traveler from the State of Hawaii Travel Quarantine (or County policy).

(b) After obtaining an Immunized Traveler waiver from PHNSY &IMF, if travelers failed to meet the requirements stated above (i.e. State of Hawaii did not exempt the traveler), the company shall immediately contact the PHNSY & IMF POC listed in the Immunized Traveler Waiver, and the impacted travelers are prohibited from entering DOD workplace for 10-days upon arrival.

3. Routing: PHNSY&IMF POC with requesting contractor/organization will complete the information sections as applicable and sign the requests. PHNSY&IMF POC can sign for requesting organization based email documentation. PHNSY&IMF POC will obtain approval from Code 1130/106 POCs with the copies of the Vaccination Record Cards or information. Code 1130/106 will review, provide comments and approval/disapproval determination with signature.

For Contractors and Subcontractors

APPENDIX B

Travelers

RANK/RATE NAME AGE DEPART RETURN REASON FOR TRAVEL (why is this person required)