The Census Bureau will use this common form to promote the safety of our Federal buildings, and Federal workforce consistent with 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. Specifically, this form will be used by Census Bureau staff charged with implementing and enforcing workplace safety protocols when requesting attestation of vaccination status from onsite contractors and visitors. The information collected on this form is not being collected, maintained, or retained by the Census Bureau. If that changes, a Privacy Act statement or other assurance of confidentiality, as appropriate, will be provided and the request for use will be revised.
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing