NASA COVID-19 Vaccine Attestation Form

NASA

Online Questionnaire

Full Name (Last, First)* _________________________________

Middle Name _________________________________

Email Address* _________________________________

Employee Badge Number _________________________________

Your NASA Center* [Drop Down List containing the following options]

NASA Headquarters (HQ)

Ames Research Center (ARC)

Armstrong Flight Research Center (AFRC)

Glenn Research Center (GRC)

Goddard Space Flight Center (GSFC)

Johnson Independent Verification and Validation Facility (IV&V)

Jet Propulsion Laboratory (JPL)

Johnson Space Center (JSC)

Kennedy Space Center (KSC)

Langley Research Center (LaRC)

Marshall Space Flight Center (MSFC)

Michoud Assembly Facility (MAF)

NASA Shared Services Center (NSSC)

Stennis Space Center (SSC)

Wallops Flight Facility (WFF)

White Sands Test Facility (WSTF)

Supervisor’s Email* _________________________________

Employer [Searchable Drop Down List containing all contractor, subcontractor, and other research and/or academic organizations that are currently associated with NASA through formal agreement]

NASA Employee Type [Drop Down List containing the following options]

NASA Civil Servant (NCIVSERV)

NASA Contractor (NCONTRCTR)

Non-NASA Civil Servant (NNCIVSERV)

Non-NASA Contractor (NNCONTRCTR)

Not Otherwise Identified (OTHER)

Pending (PENDING)

Uniformed Services (UNIFSERV)

Click on NEXT below for the questionnaire that you need to complete*

Certification of Vaccination (ATTEST)

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Certification of Vaccination

Please check the box below that coincides with your vaccination status and return this attestation form to [recipient]

by .

I am fully vaccinated.

Employees are considered “fully vaccinated” two weeks after completing the second dose of a two-dose COVID-19 vaccine (e.g., Pfizer or Moderna) or two weeks after receiving a single dose of a one-dose vaccine (e.g., Johnson & Johnson/Janssen).

I am not yet fully vaccinated—I 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. I decline to respond.

Employees who choose not to complete the form will be assumed to be not fully vaccinated for

purposes of application of the safety protocols. If you are not vaccinated due to medical or religious reasons, please check either “I have not been vaccinated” or “I decline to respond.” Note that if you have already received one dose of a vaccine, but are not yet fully vaccinated, or if you received your final dose less than two weeks ago, then you will be treated as not fully vaccinated until you are at least two weeks past your final dose and resubmit your vaccination information.

I attest that the information provided in this form is accurate and true to the best of my knowledge.

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 making a false statement on this form could result in additional administrative action including an adverse personnel action up to and including removal from my position.

Certification of Vaccination for Federal Employees

Privacy Act Statement

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.

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 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, NASA 10HIMS, Health Information Management System, 85 Fed. Reg. 79224 (December 9, 2020). https://www.govinfo.gov/content/pkg/FR-2020-08-04/pdf/2020-16863.pdf

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.

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