FCC Form 5644 VACCINATION AND ATTESTATION DOCUMENTATION FORM

FCC Form 5644

OMB Control No. 3060-XXXX
Estimated Time Per Response: 0.25 hours
November 2021

VACCINATION AND ATTESTATION DOCUMENTATION FORM
Government-wide policy requires all Federal employees and staff, including unpaid interns, unpaid legal
fellows, individuals working under an intergovernmental personnel agreement, members of advisory
committees, and other unpaid individuals performing functions at the behest of and for the Federal
Communications Commission (FCC), to be vaccinated against COVID-19, with exceptions only as required
by law. The FCC may also ask for other information, as needed. The FCC is required to keep confidential any
medical information provided, subject to the applicable Rehabilitation Act standards. Employees who
receive an exception or a delay from the vaccination requirement must comply with alternative health
and safety protocols.
Signing this form constitutes a declaration that the information you provide is true and correct to the best
of your knowledge and ability. Any intentional misrepresentation to the Federal Government may result
in legal consequences, including termination or removal from Federal Service.
Privacy Act Statement
Authority: The authority to collect this information derives from General Duty Clause; Section 5(a)(1) of
the Occupational Safety and Health (OSH) Act of 1970 (29 U.S.C. 654); Executive Order 12196,
Occupational safety and health programs for Federal employees (Feb. 26, 1980); Executive Order 13991,
Protecting the Federal Workforce and Requiring Mask-Wearing; Executive Order 14043, Requiring
Coronavirus Disease 2019 Vaccination for Federal Employees; OMB Memorandum M 21–15, COVID–19
Safe Federal Workplace: Agency Model Safety Principles (Jan. 24, 2021), as amended; and the National
Defense Authorization Act For Fiscal Year 2017 (5 U.S.C. 6329c(b)). Information will be collected and
maintained in accordance with the Rehabilitation Act of 1973 (29 U.S.C. 791 et seq.).
Purpose: The FCC collects information in this system to assist with maintaining a safe and healthy
workplace, to protect FCC staff and visitors from risks associated with a public health emergency, such
as a pandemic or epidemic, and to comply with mandates regarding travel, vaccination, testing, building
occupation, etc.
Routine Uses: The FCC may release information contained in this system to other individuals and
entities when necessary and appropriate under 5 U.S.C. § 552a(b) of the Privacy Act, including: to
federal, state, and local health agencies to the extent necessary to comply with laws and regulations
governing reporting of infectious disease; to the FCC staff member’s emergency contact for purposes of
locating a staff member during a public health emergency or to communicate that the FCC staff member
may have potentially been exposed to an infectious disease as the result of a pandemic or epidemic
while visiting a FCC facility; to comply with federal laws requiring disclosure of the information
contained in our records; to comply with requests from Congress; to other federal agencies or to other
administrative or adjudicative bodies before which the FCC is authorized to appear; to federal, state, or
local law enforcement when FCC becomes aware of an indication of a violation or potential violation of a
civil or criminal statute, law, regulation, or order; to Federal agencies, non-Federal entities, their
employees, and agents for the purpose of detecting and preventing fraud, waste, and abuse in Federal
programs; to appropriate agencies, entities, and persons when the FCC suspects or has confirmed that
there has been a breach of information related to this system of records; and, to third parties, including

contractors, performing or working on a contract in connection with providing services to the Federal
Government, who may require access to this system. A complete list of the routine uses can be found in
the system of records notice associated with this collection, FCC/OMD-33, Ensuring Workplace Health
and Safety in Response to a Public Health Emergency, 86 Fed. Reg. 32674 (June 22, 2021).
Consequence of Failure to Provide Information: Providing this information is required and failure to do
so may result in disciplinary action for federal staff and/or being denied access to FCC facilities. In
providing this information, the submitter authorizes release of the information pursuant to the routine
uses set forth in the systems of record notice.
We have estimated that your response to this collection of information will take an average of 15
minutes or 0.25 hours. Our estimate includes the time to read the instructions, look through existing
records, gather and maintain required data, and actually complete and review the form or response. If
you have any comments on this estimate, or on how we can improve the collection and reduce the
burden it causes you, please write the Federal Communications Commission, Office of Managing
Director, AMD PERM, Washington, DC 20554, Paperwork Reduction Act Project (3060-XXXX). We will
also accept your PRA comments via the Internet if you send an e-mail to [email protected].
Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. For those respondents who are not current
paid employees of the FCC (e.g., incoming employees, unpaid interns, unpaid legal fellows, individuals
performing work for the FCC pursuant to an interagency agreement, members of advisory committees,
etc.), you are not required to respond to a collection of information sponsored by the Federal
government, and the government may not conduct or sponsor this collection, unless it displays a
currently valid OMB control number and/or we fail to provide you with this notice. This collection has
been assigned an OMB control number of 3060-XXXX. Paid employees of the FCC are required to
respond regardless of the presence of an OMB control number and whether this notice has been
provided.
THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13,
OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

Vaccination Attestation and Documentation
Vaccination Status Attestation and Documentation
Name

Please check the box below that coincides with your vaccination status.
**Choices
1. 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).
2. I am not yet fully vaccinated—I received my first dose of Moderna or Pfizer, or I received my
final dose less than two weeks ago.
3. I have not been vaccinated.

Example -

Product Name/Manufacturer
1.
2.
3.
4.

Pfizer-BioNTech
Moderna
Johnson & Johnson / Janssen
Other

For Pfizer-BioNTech, Moderna, and Johnson & Johnson / Janssen
First Dose Lot Number

First Dose Date

First Dose Healthcare Professional/Clinic Site

Second Dose Lot Number

Second Dose Date

Second Dose Healthcare Professional/Clinic Site

Example -

For Other Product Name/Manufacturer
Other Vaccine Name

First Dose Lot Number

First Dose Date

First Dose Healthcare Professional/Clinic Site

Second Dose Lot Number

Second Dose Date

Second Dose Healthcare Professional/Clinic Site

Example -

Please click on the link below to upload required documentation to prove vaccination. Acceptable
documentation includes a copy of the record of immunization from a health care provider or pharmacy;
a copy of the COVID-19 Vaccination Record Card; a copy of medical records documenting the
vaccination; a copy of immunization records from a public health or state immunization information
system; or a copy of any other official documentation containing required data points. The data that
must be on any official documentation are the type of vaccine administered, date(s) of administration,
and the name of the health care professional(s) or clinic site(s) administering the vaccine(s); however, if
an official immunization record from a public health or state immunization information system does not
routinely include the name of the health care professional(s) or clinic site(s), that record may still be

submitted. A digital copy of such records, including, for example, a digital photograph, scanned image,
or PDF of such a record that clearly and legibly displays the information outlined above is acceptable.

Proof of Vaccination
Required - Upload

I certify under penalty of perjury that the information on this form and the documentation that I have
submitted are true and correct. 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). I understand that making a false
statement on this form or submitting documentation that is not true or correct could result in additional
administrative action including an adverse personnel action up to and including removal from my
position.

I attest that the information provided in this form and the attached documentation are accurate and
true to the best of my knowledge. Executed on 11/5/2021.

Example –