Weekly Attestation of Negative COVID-19 Self-Cert for DoD KTRs.pdf

NA VSEANOTE 6220

22 Dec 2021

NAVSEANOTE 6220 (Dec. 2021)

WEEKLY ATTESTATION OF NEGATIVE

COVID-19 SELF-CERTIFICATION FOR DoD CONTRACTORS

PRIVACY ACT STATEMENT

·1y: Pursuant to 5 U.S.C. chapter.; 11 and 70. and in discharging tt,e funcbons directed under Executive Order 14043, Requiring Coronavirus ase 2010 Vaccinalion for Federal E� (Sept. 0. 2021 ). DoD is authorizled ID oollect this infcrmation. Adartional aulhorities for the systems of associated with this oolledion of mormation also inckJde: E.O. 13991, Proteding the Federal Wonrorce and Requiring Mask-Wearing: E.O.

2106. �onal Safety and Healltt 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 Direclive 552521; and DoD lnstruclion 6200.03. Providing this infoonalion is mandalCl'y and OoO is au1horized to inpose enalties fort.rue to prc¥ide the infDnna1ion pu15Uanl ID applicable Federal personnel laws and regulations.

rincipal Purpose: This infonnation is being collected and maintained to implement Coronawus Disease 2019 (COVID-19) workplace safety plans.

nd enwre the safely and protection of the OoD wortforce, wonplace, and other DoD facilities and environments, consistent with the abow-n!ferenced uthorities, the COVID-19 Wonplace Safety: Agency Model Safety Principles eslablished by the Safer Fede,al Worllforce Task Force. and guidance the Cent&rs for Disease Control and Prevention and the Occupational Safety and Health Adrniniwabon.

outine Use(s): While the infoonarion requested on this form is intended to be used primariy for internal purposes. in Ol!ftain circumstances ii may be cessary to disclose this infoonation externally. for example to dlSdose information to: a person. organiz:abcn or governmental entity as necessary and levant to notify them of, respond to. or guard againY a put,llc heallh emergency. or oeher simiur crisis, inwding to cOf1'4)ly with laws gcvernilg the

· of convnunicable disease or other laws concerning health and safety il the won environment; adjudicative bodies (e.g. the Merit Sysiem rotec:tion Board), arbitralDB, and hearilg examiners to the extent necessary to eary out U- authorized duliK regarding Federal eff'4)1oyment.

ctors. grantees. experts, consultants. students. and other.; as necessary to perfcnn 111K duties for the Federal government or agencies. courts, nd persons as necessa,y and relevant in the course of rmgation, and as il aC00fdance wl1h requirements for law enforoernent; or to a person uthorized to act on your behalf.

co�lete liY of routine uses may be found in the applicable Syslem of Records Notice (SORN) associated wilh !he collection of this lllfonnatJon as : For most Federal ciVEn employees: OPMIGOVT-10. Employee Medical File System Records. 75 Fed. Reg. 35099 {Jun.21.2010), amended

Fed. Reg. 74815 (Nov. 30, 2015). For Federal ' employees not CO¥ered by OPM/GOVT-10: OPR 39 DoD. DoD Pe™>Mel Accountability and ssrnent System of Records, 85 Fed. Reg. 17047 {Mar.26.2020) (also available at hllps://dpcid.defense.gov!Portals/49/0ocunents/Privacy/

ORNs/OSOJSIOPR-39-0oD.pdf).

onsequences of Failure to Provide Information: Ploviding this information i, ll\ilfldalafy. Failure to provide this informabon or provid:ng false nformation may, al a minimum, prevent access by the oontractor and/or oontracted personnel to OoO ·es (to include ships and submarines).

The Results From My COVID-19 TeY Ase:

For The Week Starting On:

Date Of Negative Test Report To Won Date:

certify that the information I have provided on this form and the proof of vaccnation documentation I have submitll!d is lrue and carect. I understand a knoww,g and willful false statement on this form can be punished by fine or imprisonment or bolh (18 U.S.C. 1001 ).

Printed Name Sis,lature Field: 1 I Date; I

NAVSEA 622012 (Dec. 2021) Page 1 of 1

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