9197 tracked

Attachment A: Student COVID-19 Vaccine Certification, Authorizations, and Acknowledgements and Testing Consent

INSTRUCTIONS

Why am I completing this form?

The purpose of this form is to certify my agreement to take steps to prevent the spread of COVID-19 and protect the health and safety of all individuals who live, learn, and work at Job Corps centers.

How do I complete this form?

You first must complete Section 1, choosing one of the four answers listed to identify your CURRENT COVID-19 vaccination status. After completing Section 1, you must review Section 2. Section 2.A describes acknowledgements you make in signing this document if you are not up to date on your COVID-19 vaccination. If you answer that you are up to date or partially vaccinated, Section 2.B details how, in signing this document, you authorize Job Corps, its center operators, and/or its other contractors (Job Corps) to verify your vaccination status through methods described in that section. Section 2.D describes how Job Corps will record and use your vaccination status.

How will my answers on this form affect me?

Job Corps will use your answer in Section 1 to determine what COVID-19 safety requirements will apply to you under Job Corps’ COVID-19 policies. However, you WILL NOT be removed from the program or otherwise disciplined based on any answer you provide in Section 1 below.

1. Which of the below indicates your CURRENT COVID-19 vaccination status?

____ I am up to date, as defined by the Centers for Disease Control and Prevention (CDC) guidance.

____ I am fully vaccinated, as defined by the most up-to-date Centers for Disease Control and Prevention (CDC) guidance.

____ I am partially vaccinated.

____ I am not vaccinated.

____ I decline to answer.

2. Acknowledgements and Authorizations

A. If I indicated that I am NOT up to date, or I declined to answer: In signing below I acknowledge the following:

• Unlike students who have certified that they are fully vaccinated, I will be subject to enhanced quarantine, testing, and physical distancing requirements, as described in Job Corps’ COVID-19 policies.

• I must comply with these enhanced safety requirements as a condition of my enrollment and participation in the Job Corps program, unless I am eligible for a reasonable accommodation due to a disability and/or a sincerely held religious belief, practice, or observance (which will be determined on a case-by-case basis), and providing a reasonable accommodation would not impose an undue burden on Job Corps.
  
  

• If I declined to answer, I can change this answer at any time and disclose vaccination status by completing a new copy of this form.

• If I do not wish to receive vaccination or reach up to date vaccination at this time, I can later choose to receive vaccination and receive Job Corps assistance in obtaining all COVID-19 vaccine doses needed to reach up to date vaccination as defined by the CDC.
  
  

• If I later choose to pursue up to date vaccination, or need assistance arranging the CDC-recommended vaccination dosage necessary to reach up to date vaccination, Job Corps will arrange vaccination on my behalf and transport me as necessary to receive all CDC-recommended vaccination doses, unless I choose to handle these arrangements myself. These arrangements will result in no cost to me, and I will not have to pay for the vaccination.

• If I later choose to initiate or complete vaccination, I will remain subject to enhanced testing requirements until I reach up to date vaccination status, as defined by CDC guidance, unless I qualify for a reasonable accommodation as described above.

• I will complete a new copy of this form any time my vaccination status changes. My vaccine status may change because of changes to CDC guidance or because I have received a partial or full dosage of the vaccine. If my vaccination status changes, I will complete a new form.

B. If I indicated that I am up to date or not yet fully vaccinated: In signing below I authorize Job Corps to use one or more of the following methods to verify my CURRENT vaccination status, which Job Corps will add to my Student Health Record.¹

• Examination and scanning, photographing, and/or photocopying of my CDC-issued COVID-19 vaccination card or other government-issued proof of vaccination to affirm that I received the vaccine.

• Collection of medical records regarding the COVID-19 vaccination from the medical provider that provided it, including but not limited to a pharmacy, doctor’s office, or health clinic. I understand that I might need to complete a separate authorization form supplied by the provider or Job Corps to ensure the release of this information.

• Verification through the Immunization Information System (IIS), a system that tracks COVID-19 and other vaccinations. I understand that I might need to complete a separate authorization form supplied by the state in which I received vaccination to ensure the release of this information.

C. Regardless of vaccination status, in signing below, I consent to Job Corps center-provided COVID-19 testing in all circumstances recommended in CDC guidance. I also agree to surveillance testing where applicable to me, which may be necessary due to my vaccination status (as answered in Section 1) or my status as a non-residential student.

D. In signing below, I understand that my COVID-19 vaccination status, and any records collected to verify my vaccination will be added to my Student Health Record, part of ETA Form 640 (OMB Control No. 1205-0219: Standard Job Corps Contractor Information Gathering). I also acknowledge that this means Job Corps may use my COVID-19 vaccination information as applicable under the terms of health information disclosure authorizations that I have previously provided, or may provide in the future, to Job Corps in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Existing disclosures authorizations include:

• Job Corps Policy and Requirements Handbook Form 2-01: Authorizing disclosure when necessary to inform student health treatment or meet routine public health or legally required uses of health information.

• Job Corps Policy and Requirements Handbook Form 6-02: Authorizing disclosure as needed to carry out the suite of supports and services provided by Job Corps to ensure student and graduate success.

Your printed name here: ____________________________________________________________________________

Your signature here:

____________________________________________________ Date: ____________________

Parent/guardian signature (if younger than 18):

____________________________________________________ Date: ____________________

OMB Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Room N-4456, 200 Constitution Avenue, NW, Washington, DC 20210 and reference the OMB Control Number 1205-0548: COVID-19 Symptom Tracker for Students, Emotional Wellness Form for Students, and Student Vaccination Status and Test Consent Form Collection. Note: Please do not return the completed Certifications and Authorizations Related to Enrollee and Current Student COVID-19 Vaccination Status form to this address and reference the OMB Control Number 1205-0548.

OMB Control Number: 1205-0548

OMB Expiration date: 4/30/25

Form Number ETA- 9197

1 Job Corps policy (located at Policy and Requirements Handbook Appendix 202) is that any medical or disability-related information obtained about a particular individual, including information that could lead to the disclosure of a disability, must be collected on separate forms. All such information, whether in hard copy, electronic, or both, are maintained in one or more separate files, apart from any other information about the individual, and treated as confidential. Whether these files are electronic or hard copy, they are locked or otherwise secured (for example, through password protection).