DOE F 231.2 Certification of Vaccination DOE Onsite Support Service

DOE F 231.2

OMB Control No. 3206-0277
Exp. Feb. 5, 2022

Certification of Vaccination - DOE Onsite Support Service Contractor Employees
The purpose of this form is to take steps to prevent the spread of COVID-19 and to protect the health and safety of all
Department of Energy (DOE) employees as well as DOE contractor employees who perform work in a Federal government
owned or leased facility (pre-COVID-19), are embedded with DOE staff, and are employees of a support service contractor
(also referred to as “onsite support service contractor employees”). This form is for use by onsite support service contractor
employees, even if those contractor employees are not currently accessing Federal buildings during the COVID-19 pandemic
(e.g., on telework, travel). If you fail to submit this signed attestation, you will be treated as not fully vaccinated for the
purposes of implementing safety measures, including with respect to mask wearing, physical distancing, testing, travel, and
quarantine. Failure to take or provide proof of any required COVID-19 test, may result in being denied entry to a Federal
facility or, your employer enforcing any rights they may have against you, consistent with the terms of its contract with DOE
and any applicable collective bargaining agreement.

My Vaccination Status
By checking the box below, I declare that the following statement is true:
Name:

Johnny Dicus

Departmental Element: CHIEF INFORMATION OFFICER
Sub-Organization:

Email Address:

[email protected]

Organizational Placement: DEPUTY CIO FOR ARCHITECTURE, ENGIN

ENTERPRISE PROGRAM AND PRODUCT INNO My Duty Location:

IDAHO FALLS, ID

Thevaccinated.
Centers for Disease Control and Prevention considers an individual fully vaccinated if they are:
I am fully
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
yetI fully
vaccinated.
Either
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
vaccinated.
If youbeen
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.

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DOE F 231.2

OMB Control No. 3206-0277
Exp. Feb. 5, 2022

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 as an employee of an
onsite support services contractor, making a false statement on this form could result in my employer enforcing any rights
they may have against me, including discontinuing my working on the support services contract, consistent with any
applicable collective bargaining agreement.
Your printed name here:
Johnny Dicus
Your signature here:

Date/Time Field

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DOE F 231.2

OMB Control No. 3206-0277
Exp. Feb. 5, 2022

Directions and notice to employees who perform work in a Federal government owned or leased facility, are
embedded with DOE staff, and are employees of a support service contractor (onsite support service contractor
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.
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, DOE 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.
Onsite support service contractor employees who disclose that they are fully vaccinated will comply with DOE guidance for
fully vaccinated individuals. Onsite support service contractor employees who are unvaccinated, are not fully vaccinated, or
who choose not to provide vaccine information are required to comply with CDC and DOE 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 work on the contract.
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: DOE is authorized to collect the information requested on this form pursuant to the Atomic Energy Act of 1954,
(42 U.S.C. 2051a), section 31a; the Economy Act of 1932, as amended, (31 U.S.C. section 1535); 42 U.S.C. 7101 et seq.; 50 U.S.C.
2401 et seq. This information is being collected to implement Executive Order 13991, Protecting the Federal Workforce and
Requiring Mask-Wearing (Jan. 20, 2021).
Purpose: This information is being collected and maintained to promote the safety of Federal buildings and the Federal and
onsite support service contractor 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 Centers for
Disease Control and Prevention and the Occupational Safety and Health Administration.

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DOE F 231.2

OMB Control No. 3206-0277
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Routine Uses: The Information requested on this form is intended primarily for internal DOE purposes, to include helping to
ensure that social distancing between vaccinated and unvaccinated individuals is maintained and other pandemic-related
safety requirements are met. To this end, the vaccination status of individuals accessing Federal facilities may be shared with
other individuals with a need to know for reasons to include: they manage building and/or facility access or are responsible
for planning meetings and overseeing work assignments, etc. In certain circumstances, it may be necessary to disclose this
information externally. Examples include: physicians; the U.S. Department of Labor; various state departments of labor and
industry groups; contractors to (a) ascertain suitability of an employee for job assignments with regard to health (b) provide
benefits under federal programs or contracts and (c) maintain a record of occupational injuries or illnesses and the
performance of regular diagnostic and treatment services to patients; DOE contractors in performance of their contracts, and
their officers and employees who have a need for the record in the performance of their duties; the appropriate local, state or
federal agency when records alone or in conjunction with other information, indicates a violation or potential violation of law
whether civil, criminal, or regulatory in nature, and whether arising by general statute or particular program pursuant thereto;
members of DOE advisory committees; the Department of Health and Human Services Advisory Committee on Projects
Related to Department of Energy Facilities; and to designated employees of Federal, State, or local government or
government-sponsored entities authorized to provide advice to the Department concerning health, safety or environmental
issues. A complete list of the routine uses can be found in the system of records notice associated with this collection of
information, DOE-33, Personnel Medical Records, 74 Fed. Reg. 993, 1032 (January 9, 2009).
Additional Information: Respondents are not required to provide supporting documentation with this for. Do not submit a
copy of a vaccination card or other medical documentation at this time.
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 [email protected] or by calling 202-586-2683 (202-586-COVD) with questions.

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DOE F 231.2

OMB Control No. 3206-0277
Exp. Feb. 5, 2022

Paperwork Reduction Act Burden Disclosure Statement
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to [email protected] (subject line: Certificate of
Vaccination, OMB Control Number 1910-XXXX).
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a
penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act
unless that collection of information displays a currently valid OMB control number.

Signature:

Johnny Dicus

Johnny Dicus (Aug 25, 2021 13:47 EDT)

Email: [email protected]

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