S-DASOBO-00001174_AttH_Form of Certification.pdf

I have documentation confirming all Workers from my company who work onsite at the above listed worksite are fully vaccinated against COVID-19, as required by EO 21-29.

I have documentation confirming that all Workers from my company who work onsite at the above listed worksite are either fully vaccinated against COVID-19 or have an approved medical exception or have an approved religious exception, as required by EO 21-29. I have a written accommodation plan for each approved exception.

I do not have documentation confirming that all Workers at the above listed are in compliance with EO 21-29

I decline to respond

I acknowledge that substitute, replacement, additional or new Workers are subject to this EO-21-29 and I will maintain documentation confirming compliance with EO 21-29 during the term of this contract or the duration of EO 21-29 whichever first expires or terminates.

By signature below, the undersigned Authorized Representative on behalf of Contractor certifies to the best of his or her knowledge and belief that the responses provided on this form are complete, accurate, and not misleading.

Date: ________________________

Title: _________________________

Signature: __________________________________

Printed Name: ______________________________

For questions about this form, contact

On August 13, 2021, Governor Kate Brown signed Executive Order (EO) 21-29. The purpose of the EO is to protect state workers, their coworkers and the public that relies on state services from the effects of COVID-19. This EO requires, in part, that Executive Branch state agencies have documentation that all workers are in compliance with the requirements of the EO. Per section 1.f., a Worker is an individual who is not employed by the state of Oregon but is engaged to provide goods or services to the Executive Branch through any formal or informal agreement; and where the goods or services are performed in person and on site at an Executive Branch worksite.

The purpose of this form is to document compliance with EO 21-29. If you fail to submit this signed document, you, your employees, and your subcontractors may be denied access to the worksite. A failure to comply with EO 21-29 may be a breach of contract and could result in termination of the contract.

The undersigned also understands that any statement or representation it makes, 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)}, 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.

(Agency name) _________________________________________________ has determined that (Contractor name) _______________________________________________ has Workers at the address _________________________________ under Contract number __________________.

By checking the box below, I declare that the following statement is true:

Executive Order 21-29 Vaccination Compliance Form Agency Contract Administrators can choose to either pre populate the applicable fields below or ask the contractor to fill out on their own. Keep the signed completed form in the procurement file.