Certification of Vaccination Common Form

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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.

[Describe the information you want from employees who will fill out this form.]

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.
Printed name:

Signature:

Date:

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, 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.

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