Form FCC Form 5644 FCC Form 5644 VACCINATION AND ATTESTATION DOCUMENTATION FORM

COVID-19 Vaccine Attestation Form for Non-paid Employees

Vaccination Status Survey Form - FINAL with Booster request redacted

Individuals or Households

OMB: 3060-1297

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Vaccination Status Survey Home - Vaccination Status Survey

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https://fccprod.servicenowservices.com/vss

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 employees. In providing this information, the submitter authorizes release
of the information pursuant to the routine uses set forth in the systems of record notice.

If you are using Assistive Technology and are unable to complete this form please contact
[email protected] for immediate assistance.
 

Federal Communications Commission
45 L Street NE
Washington, DC 20554

Phone: 1-888-225-5322
ASL Video Call: 1-844-432-2275
ASL Video Call: Web
Fax: 1-866-418-0232
Contact Us

5/23/2022, 10:39 AM


File Typeapplication/pdf
File Modified2022-06-06
File Created2022-05-25

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