Form DOE F 231.2 DOE F 231.2 Certificate of Vaccination

DOE F 231.2

Print Blank Form

OMB Control No. 1910-5194
Exp. 07/31/2022

Certification of Vaccination Verification form

Certification of Vaccination - DOE Onsite Support Service Contractor Employees
* Contractor Name:

* Department Element:

Select [or fill-in as needed on hard copy of form]
* Email Address: (provide gov address, if available)

* Organizational Placement:

Select [or fill-in as needed on hard copy of form]
* Prime Contractor Number:

* Sub-Organization:
Select [or fill-in as needed on hard copy of form]

* Prime Contractor Company Name:
* Duty Station:
* Please check the box below that coincides with your vaccination status.
Select one of the following options for your vaccination status:
- Option 1: I am fully vaccinated or pending my 2-week wait to be considered fully vaccinated.
- Option 2: I am not vaccinated.
Option 1:

I am fully vaccinated or pending my 2-week wait to be considered fully vaccinated.

* Specify Type of Vaccine

* Enter date of first dose

* State where administered

* Health care professional or clinic site administered the vaccine

* Enter date of second dose

* State where administered

* Health care professional or clinic site administered the vaccine
Enter date of third (or booster) dose

State where third (or booster) dose administered

Health care professional or clinic site administered the third (or booster) dose.

Specify the Type of third (or booster) dose vaccine

December 2021

OMB Control No. 1910-5194
Exp. 07/31/2022

DOE F 231.2

Option 2:

I am not vaccinated.

* I have accurately completed the Vaccination requirements established by the Department of Energy and I
certify under penalty of perjury that the documentation I am submitting is true and correct.
* Please type your name

December 2021

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OMB Control No. 1910-5194
Exp. 07/31/2022

Privacy Act Statement
Authority: DOE is authorized to collect the information requested on this form pursuant to Executive Order 14042,
Ensuring Adequate COVID Safety Protocols for Federal Contractors (September 9, 2021); Executive Order 14043,
Requiring Coronavirus Disease 2019 Vaccination for Federal Employees (September 9, 2021); Executive Order 13991,
Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021); and Executive Order 12196,
Occupational Safety and Health Program for Federal Employees (Feb. 26, 1980).
Purpose: This information is being collected and maintained to determine the eligibility of a contractor employee to
access DOE buildings without showing proof of vaccination or a negative COVID test each time the contractor
employee seeks access and the safety of the DOE contractor workforce consistent with the above-referenced
authorities; the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal
Workforce Task Force (see e.g.
https://www.saferfederalworkforce.gov/downloads/Draft%20contractor%20guidance%20doc_20210922.pdf); and
guidance from Centers for Disease Control and Prevention, the Equal Employment Opportunity Commission, and the
Occupational Safety and Health Administration.
Routine Uses: The information requested on this form is collected for internal DOE purposes to determine whether
DOE contractor employees may have access to DOE facilities without repeatedly having to show proof of vaccination
or a negative COVID test and protect the health and safety of the DOE federal and contractor workforce and
individuals interacting with the DOE federal and contractor workforce in DOE building workspaces. To these and
related ends, vaccination status and other information in the system may be shared with individuals with a need to
know because they manage building and/or facility access; are in an employer role for individuals submitting
information; and are responsible for planning meetings and overseeing work assignments, etc. In certain circumstances,
it may be necessary to disclose this information externally. Examples include: physicians, the U.S. Department of
Labor, various state departments of labor and industry groups, and contractors to ascertain suitability of a contractor for
job assignments, to maintain a record of occupational injuries or illnesses and the performance of regular diagnostic
and treatment services to patients; to DOE contractors in performance of their contracts, and their officers and
employees who have a need for the record in the performance of their duties; the appropriate local, state or federal
agency when records alone or in conjunction with other information, indicates a violation or potential violation of law
whether civil, criminal, or regulatory in nature, and whether arising by general statute or particular program pursuant
thereto; and to designated employees of Federal, State, or local government or government-sponsored entities
authorized to provide advice to the Department concerning health, safety or environmental issues. A complete list of
the routine uses can be found in the system of records notices DOE-33, Personnel Medical Records, and DOE-51,
Employee and Visitor Access Control Records, published in 74 Fed. Reg. 993 (January 9, 2009).
Failure to Provide Information: Completing this form is voluntary. In the alternative to completing this form, each
time you seek access to a DOE facility you must provide a copy of your vaccination card. If you are not fully
vaccinated, or you decline to provide your vaccination card, you must provide proof of a negative COVID-19 viral test
that has occurred within the previous three days prior to entry to a DOE facility. Failure to provide this information
and complete this form will result in being denied entry to a Federal facility. In addition, your employer may enforce
any rights they may have against you, consistent with the terms of its contract with DOE and any applicable collective
bargaining agreement.

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OMB Control No. 1910-5194
Exp. 07/31/2022

Paperwork Reduction Act Burden Disclosure Statement: Public reporting burden for this collection of information is
estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to DOEPRA@hq.doe.gov (subject line: Contractor Verification of Vaccination, OMB Control
Number 1910-XXXX).
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to
a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction
Act unless that collection of information displays a currently valid OMB control number.
Submission of this data is voluntary.