RFP 5396 AttH.doc

RFP #5396 – Technical Assistance For Public Water Systems Att H

ATTACHMENT H —

Sample Certification of compiance with EO 21-29 Legal Name of Proposer:

Address:

City, State, Zip:

State of Incorporation:

Entity Type:

Contact Name:

Telephone:

Email:

Oregon Business Registry Number (if required):

Any individual signing below hereby certifies they are an authorized representative of Proposer and that:

1. Proposer certifies that: during the term of the contract or the duration of EO 21-29, whichever expires or terminates first, that contractor has obtained Proof of Vaccination from all Workers providing goods or services at an Agency Worksite are Fully Vaccinated against COVID-19 or have met the requirements for an exception under paragraph 6 of EO 21-29.

The definitions below in Section 2. (“Special Definitions for Interpreting EO 21-19 Obligations”) apply to this paragraph.

2. Special Definitions for Interpreting EO 21-19 Obligations:

The following definitions are from EO 21-19 as it may be amended. These definitions are for reference only and Proposers should refer to the EO 21-29 for current definitions.

· “EO 21-29” means Governor of the State of Oregon’s Executive Order 21-29, https://www.oregon.gov/gov/Documents/executive_orders/eo_21-29.pdf.

· "Executive Branch" has the meaning given to the term Executive Department in ORS 174.112.

· "COVID-19" means a disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

· "Fully Vaccinated" means having received both doses of a two-dose COVID-19 vaccine or one dose of a single-dose COVID-19 vaccine and at least 14 days have passed since the individual's final dose of COVID-19 vaccine.

· "Proof of Vaccination" means documentation provided by a tribal, federal, state or local government, or a health care provider, that includes an individual's name, date of birth, type of COVID-19 vaccination given, date or dates given, depending on whether it is a one-dose or two-dose vaccine, and the name and location of the health care provider or site where the vaccine was administered. Documentation may include but is not limited to a COVID-19 vaccination record card, a copy or digital picture of the vaccination record card, or a print-out from the Oregon Health Authority's immunization registry.

· "Employee" means any person employed by the Executive Branch, but does not include individuals whose only work for the Executive Branch is as a volunteer board, commission, or council member, and whose compensation is limited to a stipend or per diem; does not include elected or appointed District Attorneys; and does not include Workers.

· "Worker" means an individual who is not an Employee, and is engaged to provide goods or services to the Executive Branch through any formal or informal agreement, whether compensated or uncompensated, including Oregon Corrections Enterprises, but does not include a visitor, patron, adult in custody, or board, commission, or council member. Individuals are exempt from the definition of Worker unless any provision of the agreement to provide goods or services requires work to be performed in person and on site at an Executive Branch worksite, regardless of frequency, whether other persons are present, or any contingent nature of that requirement. Persons making deliveries or pick-ups to Executive Branch worksites are not considered Workers.

The following definition of Worksite is from the Executive Order 21-29 Vaccination Requirements for State Contractors Frequently Asked Questions as may be amended and is for reference only. Proposers should refer to the FAQ for the most recent definition.

ExecutiveOrder21-29_ContractorFAQ.pdf (oregon.gov) “Worksite” means any indoor premises controlled or operated by an Executive Branch agency, where a Worker performs services in person for longer than 15 minutes (“close contact” as defined by the Centers for Disease Control and Prevention). For leased spaces including multi-tenant environments, this includes only the spaces and services under the control of the agency, it excludes landlord provided services and doesn’t include common areas or other areas not within the control of the Agency.

3. Proposer understands that any statement or representation it makes, in response to this RFP, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under Contract being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

4. Proposer acknowledges these certifications are in addition to any certifications required in the Contract and Statement of Work in Attachment A at the time of Contract execution.

Authorized Signature

Date

COMMENTS \* FirstCap \* MERGEFORMAT DAS Procurement Services, Version 4.0 – December 21, 2018