Form 3 Building Access Form

2/1/22, 10:07 AM

AndorNow

Certification of Vaccination

OMB#: 0925-0771 Expiration date: 03/31/2022
Public reporting burden for this collection of information is estimated to average 5 minute 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. An Agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a current valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to NIH, Project clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-0771). Do not return the completed form to this address.
NIH Campus Certification of Vaccination
The purpose of this attestation is to take steps to prevent the spread of COVID-19, to protect the health and safety of all
Federal employees, onsite contractors, visitors to Federal buildings or Federally controlled indoor workspaces, and other
individuals interacting with the Federal workforce. If you fail to complete this attestation or any required negative
COVID-19 test, you may be denied entry to a Federal facility.
Once complete, share your results with the staff member at the campus entrance.
I am completing this document under penalty of perjury that the response is true and correct, and that I am the person
completing it. I understand that a knowing and willful false statement on this form can be punished by fine or
imprisonment or both (18 U.S.C. 1001). Checking “I decline to respond” does not constitute a false statement. I understand
that if I am a Federal employee or contractor making a false statement on this form could result in additional
administrative action.
We will not store or share your data.

Terms and Conditions
Consistent with guidance from the Centers for Disease
Control and Prevention (CDC) and the Safer Federal
Workforce Task Force, has established specific safety
protocols for fully vaccinated people and not fully
vaccinated people, respectively. You may be asked to
submit this completed form to your employing agency.
In areas of low or moderate transmission, as defined by
CDC, fully vaccinated people generally can safely
participate in most activities, indoor or outdoor, without
needing to wear a mask or maintain physical distance,
and do not need to undertake regular testing—please
note that consistent with CDC guidance, agencies may
have different protocols for fully vaccinated people in
specific work settings, such as healthcare settings. In
areas of high or substantial transmission, everyone,
including fully vaccinated people, must wear a mask
consistent with Federal requirements.
Employees who disclose that they are fully vaccinated
will comply with agency guidance for fully vaccinated
individuals Employees who are unvaccinated are not
I agree with this Terms and Conditions.

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2/1/22, 10:10 AM

AndorNow

Certification of Vaccination

OMB#: 0925-0771 Expiration date: 03/31/2022
Public reporting burden for this collection of information is estimated to average 5 minute 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. An Agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a current valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to NIH, Project clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-0771). Do not return the completed form to this address.
NIH Campus Certification of Vaccination
The purpose of this attestation is to take steps to prevent the spread of COVID-19, to protect the health and safety of all
Federal employees, onsite contractors, visitors to Federal buildings or Federally controlled indoor workspaces, and other
individuals interacting with the Federal workforce. If you fail to complete this attestation or any required negative
COVID-19 test, you may be denied entry to a Federal facility.
Once complete, share your results with the staff member at the campus entrance.
I am completing this document under penalty of perjury that the response is true and correct, and that I am the person
completing it. I understand that a knowing and willful false statement on this form can be punished by fine or
imprisonment or both (18 U.S.C. 1001). Checking “I decline to respond” does not constitute a false statement. I understand
that if I am a Federal employee or contractor making a false statement on this form could result in additional
administrative action.
We will not store or share your data.

Terms and Conditions
Consistent with guidance from the Centers for Disease Control and Prevention (CDC) and the Safer Federal
Workforce Task Force, has established specific safety protocols for fully vaccinated people and not fully vaccinated
people, respectively. You may be asked to submit this completed form to your employing agency.
In areas of low or moderate transmission, as defined by CDC, fully vaccinated people generally can safely
participate in most activities, indoor or outdoor, without needing to wear a mask or maintain physical distance, and
do not need to undertake regular testing—please note that consistent with CDC guidance, agencies may have
different protocols for fully vaccinated people in specific work settings, such as healthcare settings. In areas of high
or substantial transmission, everyone, including fully vaccinated people, must wear a mask consistent with Federal
requirements.
Employees who disclose that they are fully vaccinated will comply with agency guidance for fully vaccinated
individuals. Employees who are unvaccinated, are not fully vaccinated, or who choose not to provide vaccine
information are required to comply with CDC and agency guidance for not fully vaccinated individuals, including
wearing masks regardless of the transmission rate in a given area, physical distancing, regular testing, and
adhering to applicable travel restrictions. These requirements are to prevent the spread of COVID-19 to protect the
health and safety of our workforce. Making a false statement on this form could result in an adverse personnel
action against you, up to and including removal from your position.
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement informs you of why you are being asked to provide this
information.
I agree with this Terms and Conditions.

Continue

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2/1/22, 10:10 AM

AndorNow

Certification of Vaccination

OMB#: 0925-0771 Expiration date: 03/31/2022
Public reporting burden for this collection of information is estimated to average 5 minute 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. An Agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a current valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to NIH, Project clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-0771). Do not return the completed form to this address.
NIH Campus Certification of Vaccination
The purpose of this attestation is to take steps to prevent the spread of COVID-19, to protect the health and safety of all
Federal employees, onsite contractors, visitors to Federal buildings or Federally controlled indoor workspaces, and other
individuals interacting with the Federal workforce. If you fail to complete this attestation or any required negative
COVID-19 test, you may be denied entry to a Federal facility.
Once complete, share your results with the staff member at the campus entrance.
I am completing this document under penalty of perjury that the response is true and correct, and that I am the person
completing it. I understand that a knowing and willful false statement on this form can be punished by fine or
imprisonment or both (18 U.S.C. 1001). Checking “I decline to respond” does not constitute a false statement. I understand
that if I am a Federal employee or contractor making a false statement on this form could result in additional
administrative action.
We will not store or share your data.

Terms and Conditions
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement informs you of why you are being asked to provide this
information.
Authority: We are authorized to collect the information requested on this form pursuant to Executive Order 13991,
Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), Executive Order 12196, Occupational
Safety and Health Program for Federal Employees (Feb. 26, 1980), and 5 U.S.C. chapters 11 and 79.
Purpose: This information is being collected and maintained to promote the safety of Federal buildings and the
Federal workforce consistent with the above-referenced authorities, 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.
Routine Uses: While the information requested on this form is intended to be used primarily for internal purposes, in
certain circumstances it may be necessary to disclose this information externally, for example to disclose
information to: a Federal, State, or local agency to the extent necessary to comply with laws governing reporting of
communicable disease or other laws concerning health and safety in the work environment; to adjudicative bodies
(e.g., the Merit System Protection Board), arbitrators, and hearing examiners to the extent necessary to carry out
their authorized duties regarding Federal employment; to contractors, grantees, or volunteers as necessary to
perform their duties for the Federal government; to other agencies, courts, and persons as necessary and relevant
in the course of litigation, and as necessary and in accordance with requirements for law enforcement; or to a
person authorized to act on your behalf. A complete list of the routine uses can be found in the system of records
/
I agree with this Terms and Conditions.
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2/1/22, 10:16 AM

AndorNow

Certification of Vaccination

OMB#: 0925-0771 Expiration date: 03/31/2022
NIH Campus Certification of Vaccination
The purpose of this attestation is to take steps to prevent the spread of COVID-19, to protect the health and safety of all
Federal employees, onsite contractors, visitors to Federal buildings or Federally controlled indoor workspaces, and other
individuals interacting with the Federal workforce. If you fail to complete this attestation or any required negative
COVID-19 test, you may be denied entry to a Federal facility.
Once complete, share your results with the staff member at the campus entrance.
I am completing this document under penalty of perjury that the response is true and correct, and that I am the person
completing it. I understand that a knowing and willful false statement on this form can be punished by fine or
imprisonment or both (18 U.S.C. 1001). Checking “I decline to respond” does not constitute a false statement. I understand
that if I am a Federal employee or contractor making a false statement on this form could result in additional
administrative action.

My vaccination status:
*Fully vaccinated means you are two weeks out from the last dose needed to complete the vaccination series.
I am fully vaccinated

(The Centers for Disease Control and Prevention considers an individual fully vaccinated if they are:

•2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or

•2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine)
I am not yet fully vaccinated

(Either I have received my first dose of Moderna or Pfizer, and my second appointment is scheduled, or I
received my final dose less than two weeks ago.)

I have not been vaccinated

(If you are not vaccinated due to medical or religious reasons, please check either “I have not been
vaccinated” or “I decline to respond.”)

I decline to respond
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2/1/22, 10:17 AM

AndorNow

OK TO PROCEED
NIH CAMPUS CLEARANCE
Valid for:

Tuesday, February 1st 2022, 10:17:13 am
Please show this screen to the staff member at the NIH campus entrance.

Thank you for helping us protect you and others during this time.

PLEASE NOTE: If you are proceeding to Building 10 (the NIH Clinical Center), you will be required to complete an additional
screening questionnaire.

Click here to access Building 10 (NIH Clinical

Center) COVID Screening
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