FCC Form 5644 VACCINATION AND ATTESTATION DOCUMENTATION FORM

6/30/22, 10:27 AM

Vaccination Status Survey Home - Vaccination Status Survey

Vaccination Status Survey
UPDATE PRIMARY VACCINATION STATUS



Vaccination Status
VSS Employee
Not Answered

SUBMIT VACCINE BOOSTER STATUS/DOCUMENTATION



SUBMIT COVID-19 TESTING RESULTS AND PROOF



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
https://fccuat.servicenowservices.com/vss

1/3

6/30/22, 10:27 AM

Vaccination Status Survey Home - Vaccination Status Survey

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 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.

Paperwork Reduction Act Statement
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the Federal Communications Commission collects
information necessary to maintain 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. 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 currently
valid OMB control number. OMB has approved this collection of information and assigned Control No. 3060-1297.
Estimated Burden Statement: We estimate public reporting for this collection of information to average 15 minutes,
including time for reviewing instructions, gathering and maintaining data and completing and reviewing the form.
Direct comments regarding the burden estimate or any other aspect of the information collection to the Federal
Communications Commission, Office of Managing Director, AMD PERM, Washington, DC 20554, Paperwork Reduction
Act Project (3060-1297). We will also accept your PRA comments via the Internet if you send an e-mail to [email protected].
THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44
U.S.C. SECTION 3507.

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

T

Y

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

https://fccuat.servicenowservices.com/vss

2/3

6/30/22, 10:27 AM

https://fccuat.servicenowservices.com/vss

Vaccination Status Survey Home - Vaccination Status Survey

3/3