Fillable Certification of Vaccination

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Certification of Vaccination

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OMB Control No. 3206-0277
Exp. Feb. 5, 2022
Certification of Vaccination
The purpose of this form is to take steps to prevent the spread of COVID-19, to protect the
health and safety of all Federal employees, onsite contractors, visitors to Federal buildings or
Federally controlled indoor workspaces, and other individuals interacting with the Federal
workforce. If you fail to submit this signed attestation or any required negative COVID-19 test,
you may be denied entry to a Federal facility.
My Vaccination Status
By checking the box below, I declare that the following statement is true:
I am fully vaccinated.
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The Centers for Disease Control and Prevention considers an individual fully vaccinated if they are:
• 2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or
• 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine
If you don’t meet these requirements, regardless of your age, you are not fully vaccinated.
I am not yet fully vaccinated.
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Either I have received my first dose of Moderna or Pfizer, and my second appointment is scheduled, or I
received my final dose less than two weeks ago.
I have not been vaccinated.
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If you are not vaccinated due to medical or religious reasons, please check either “I have not been
vaccinated” or “I decline to respond.”
I decline to respond.
I understand that if I decline to respond or am not fully vaccinated, I must comply
with the following safety protocols while in a Federal facility:
• Wear a mask regardless of the level of community transmission;
• Physically distance; and
• Provide proof of having received a negative COVID-19 test from within the previous 3 days if
I am a visitor or I am an onsite contractor who is not enrolled in an agency’s testing
program.
I sign this document under penalty of perjury that the above is true and correct, and that I am
the person named below. I understand that a knowing and willful false statement on this form
can be punished by fine or imprisonment or both (18 U.S.C. 1001). Checking “I decline to
respond” does not constitute a false statement. I understand that if I am a Federal employee or
contractor making a false statement on this form could result in additional administrative action,
OMB Control No. 3206-0277
Exp. Feb. 5, 2022
2
including an adverse personnel action up to and including removal from my position or removal
from a contract.
Your printed name here:
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our signature here:
D
ate:
Directions and notice to Federal employees
Consistent with guidance from the Centers for Disease Control and Prevention (CDC) and the
Safer Federal Workforce Task Force,
has established specific safety protocols for fully vaccinated people and not fully vaccinated
people, respectively. You may be asked to submit this completed form to your employing
agency.
In areas of low or moderate transmission, as defined by CDC, fully vaccinated people generally
can safely participate in most activities, indoor or outdoor, without needing to wear a mask or
maintain physical distance, and do not need to undertake regular testing—please note that
consistent with CDC guidance, agencies may have different protocols for fully vaccinated people
in specific work settings, such as healthcare settings. In areas of high or substantial
transmission, everyone, including fully vaccinated people, must wear a mask consistent with
Federal requirements.
Employees who disclose that they are fully vaccinated will comply with agency guidance for fully
vaccinated individuals. Employees who are unvaccinated, are not fully vaccinated, or who choose
not to provide vaccine information are required to comply with CDC and agency guidance for not
fully vaccinated individuals, including wearing masks regardless of the transmission rate in a
given area, physical distancing, regular testing, and adhering to applicable travel restrictions.
These requirements are to prevent the spread of COVID-19 to protect the health and safety of
our workforce. Making a false statement on this form could result in an adverse personnel action
against you, up to and including removal from your position.
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement informs you of why you are
being asked to provide this information.
Authority: We are authorized to collect the information requested on this form pursuant to
Executive Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20,
2021), Executive Order 12196, Occupational Safety and Health Program for Federal Employees
(Feb. 26, 1980), and 5 U.S.C. chapters 11 and 79.
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OMB Control No. 3206-0277
Exp. Feb. 5, 2022
3
Purpose: This information is being collected and maintained to promote the safety of Federal
buildings and the Federal workforce consistent with the above-referenced authorities, the
COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal
Workforce Task Force, and guidance from the Centers for Disease Control and Prevention and
the Occupational Safety and Health Administration.
Routine Uses: While the information requested on this form is intended to be used primarily
for internal purposes, in certain circumstances it may be necessary to disclose this information
externally, for example to disclose information to: a Federal, State, or local agency to the extent
necessary to comply with laws governing reporting of communicable disease or other laws
concerning health and safety in the work environment; to adjudicative bodies (e.g., the Merit
System Protection Board), arbitrators, and hearing examiners to the extent necessary to carry
out their authorized duties regarding Federal employment; to contractors, grantees, or
volunteers as necessary to perform their duties for the Federal government; to other agencies,
courts, and persons as necessary and relevant in the course of litigation, and as necessary and
in accordance with requirements for law enforcement; or to a person authorized to act on your
behalf. A complete list of the routine uses can be found in the system of records notice
associated with this collection of information, OPM/GOVT-10, Employee Medical File System of
Records, 75 Fed. Reg. 35099 (June 21, 2010), amended 80 Fed. Reg. 74815 (Nov. 30, 2015)
.
Consequence of Failure to Provide Information: Providing this information is voluntary.
However, if you fail to provide this information, you will be treated as not fully vaccinated for
purposes of implementing safety measures, including with respect to mask wearing, physical
distancing, testing, travel, and quarantine.
Please contact with questions. Please return
this form to .
Directions and notice to Federal contractors
In areas of low or moderate transmission, as defined by CDC, fully vaccinated people generally
can safely participate in most activities, indoor or outdoor, without needing to wear a mask or
maintain physical distance, and do not need to undertake regular testing—please note that
consistent with CDC guidance, agencies may have different protocols for fully vaccinated people
in specific work settings, such as healthcare settings. In areas of high or substantial
transmission, everyone, including fully vaccinated people, must wear a mask consistent with
Federal requirements.
You may be asked to show this form and/or information from a health screening upon entry to a
Federal building or Federally controlled indoor worksites, and/or to a Federal employee who is
supervising or managing your work on Federal premises. Please maintain this form during your
time on Federal premises.
Please contact with questions.
OMB Control No. 3206-0277
Exp. Feb. 5, 2022
4
Directions and notice to visitors
In areas of low or moderate transmission, as defined by CDC, fully vaccinated people generally
can safely participate in most activities, indoor or outdoor, without needing to wear a mask or
maintain physical distance, and do not need to undertake regular testing—please note that
consistent with CDC guidance, agencies may have different protocols for fully vaccinated people
in specific work settings, such as healthcare settings. In areas of high or substantial
transmission, everyone, including fully vaccinated people, must wear a mask consistent with
Federal requirements.
You may be asked to show this form and/or information from a health screening upon entry to a
Federal building or Federally controlled indoor worksites. Please maintain this form during
your visit. You may be asked to show this form as part of your in-person participation in a
Federally hosted meeting, event, or conference. If you are entering to obtain a public service or
benefit and are not fully vaccinated, you must comply with all relevant CDC guidance, including
mask wearing and physical distancing requirements, however this form and the requirement to
show a negative COVID-19 test do not apply to you.
Public burden information
Public burden reporting for this collection of information is estimated to average 2 minutes per
response, including time for reviewing instructions and completing and reviewing the collection
of information. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to PRA@opm.gov
. The
OMB clearance number 3206-0277, is currently valid.
may not collect this information, and you are not required to respond, unless this number is
displayed.
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Certification of Vaccination

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Completed 27 September 2021

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