Certification of Vaccination

OMB Control No. 3170-XXXX

Expiration Date: XX/XX/XXXX

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.	You 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/Jassen).
I am not yet fully vaccinated.	If you have received your first dose of two-dose vaccine and your second appointment is scheduled, or you received your final dose less than two weeks ago, you are not yet fully vaccinated.
I have not been vaccinated.	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

including an adverse personnel action up to and including removal from my position or removal from a contract.

Your printed name here:

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

Notice to Federal contractors

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 29 U.S.C. 668; Executive Order 12196, Occupational Safety and Health Programs for Federal Employees (Feb. 26, 1980); 29 U.S.C. 791 et seq.; 12 U.S.C. 5492; Executive Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021); and Executive Order 14042, Ensuring Adequate COVID Safety Protocols for Federal Contractors (Sept. 9, 2021).

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: an appropriate national, State, tribal, local, or territorial public health entities responsible for infection prevention and control, testing, community mitigation, surveillance and data analytics, and tracing of exposures in their respective jurisdictions; contractors, agents, or other authorized individuals performing work on a contract, service, cooperative agreement, job, or other activity on behalf of the Bureau or Federal Government and who have a need to access the information in the performance of their duties or activities; 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; to appropriate Federal, State, local, foreign, tribal, or self-regulatory organizations or agencies responsible for investigating, prosecuting, enforcing, implementing, issuing, or carrying out a statute, rule, regulation, order, or license, if the information is relevant to and indicates a violation or a potential violation of civil or criminal law, rule, regulation, order, or license within the responsibilities of the recipient agency; 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, CFPB.029, Public Health and Safety System, 86 FR 18041 (April 7, 2021).

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.

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

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The OMB control number for this collection is 3170-00XX. It expires on XX/XX/XXXX. The time required to complete this information collection is estimated to average approximately 2 minutes per response. Comments regarding this collection of information, including the estimated response time, suggestions for improving the usefulness of the information, or suggestions for reducing the burden to respond to this collection should be submitted to the Consumer Financial Protection Bureau at [email protected].

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