VA10230, COVID-19 Vaccination Form (Non-VHA Personnel)

COVID-19 VACCINATION FORM

I am a VA:

Employee Volunteer Other (ex: Trainee, Resident, Intern, Fee Basis, or Researcher)

Please indicate:

CHECK THE STATEMENT(S) FOR WHICH YOU MEET THE CRITERIA AND COMPLETE AND SIGN THE LAST SECTION OF THIS

FORM PRIOR TO SUBMISSION TO YOUR SUPERVISOR. PLEASE READ THE DESCRIPTIONS BELOW TO LEARN THE CRITERIA

TO REQUEST A MEDICAL OR RELIGIOUS EXCEPTION. YOU MAY SELECT MEDICAL EXCEPTION, RELIGIOUS EXCEPTION,

OR SELECT BOTH IF YOU MEET THE CRITERIA FOR BOTH A MEDICAL AND RELIGIOUS EXCEPTION.

FULLY VACCINATED (Required documentation attached):

I have received a complete COVID-19 vaccine series. Please complete the following information:

Type of vaccine administered:

ASTRAZENECA/OXFORD

JOHNSON AND JOHNSON (J&J)/JANSSEN

MODERNA

PFIZER

OTHER

Date(s) of Administration:

Name of health care professional, clinical site, or vaccination event that administered the vaccine:

To verify the information entered, please attach a copy of the documents showing you received your vaccine(s). Acceptable forms of

documentation include a copy of:

• The signed record of immunization from a health care provider or pharmacy,

• COVID-19 Vaccination Record Card (CDC Form MLS-319813_r, published on September 3, 2020),

• Record of immunization from a health care provider or pharmacy;

• Medical records documenting the vaccination; or

• Immunization records from a public health or state immunization information system.

FULLY VACCINATED (Attached is a VA Form 10-5345 to authorize Employee Occupational Health to release my COVID-19 vaccination record to verify

my vaccination status):

I have received a complete COVID-19 vaccine series and was vaccinated by the Veterans Health Administration (VHA). I authorize VHA

to use and disclose my health information as related to the care and treatment for infection with COVID-19, including test results and

vaccination status, to certain personnel of the Department of Veterans Affairs (VA) who have a need for the information in the performance

of their duties, to promote the health and safety of the Federal workforce and the efficiency of the civil service.

MEDICAL EXCEPTION:

I have a medical exception to receiving the COVID-19 vaccination and am requesting a reasonable accommodation. This submission will

be used to notify my supervisor to initiate the reasonable accommodation process. Approval of the requested accommodation is subject to

the outcome of the reasonable accommodation process. If the accommodation is approved, I acknowledge that according to requirements

and guidelines within the VA Notice, Mandatory Coronavirus Disease 2019 (COVID-19) Vaccination Program for VA Employees, I must:

• Wear a face mask;

• Physically distance;

• Submit to COVID-19 testing;

• Be subject to Government-wide travel restrictions on official travel; and

• Any other mitigation strategies required as part of the accommodation.

TITLE VII EXCEPTION (RELIGIOUS OR PREGNANCY EXCEPTION):

I have a sincerely held religious belief and/or pregnancy related issues (as defined in the Pregnancy Discrimation Act) that prevents me from

receiving the COVID-19 vaccine and am requesting a reasonable accommodation. This submission will be used to notify my supervisor to

initiate the reasonable accommodation process. Approval of the requested accommodation is subject to the outcome of the reasonable

accommodation process. If the accommodation is approved (and while waiting for the approval decision), I acknowledge that I must follow the

requirements and guidelines within the VA Notice, Mandatory Coronavirus Disease 2019 (COVID-19) Vaccination Program for VA Employees

• Wear a face mask;

• Physically distance;

• Submit to COVID-19 testing;

• Be subject to Government-wide travel restrictions on official travel; and

• Any other mitigation strategies required as part of the accommodation.

VA FORM

JAN 2022

10230

BOTH MEDICAL AND TITLE VII EXCEPTION (RELIGIOUS OR PREGNANCY):

I have both a medical and a sincerely held religious belief and/or pregnancy related issues (as defined in the Pregnancy

Discrimation Act) that prevents me from receiving the COVID-19 vaccine and am requesting an accommodation. This

submission will be used to notify my supervisor to initiate the reasonable accommodation process. Approval of the requested

accommodation is subject to the outcome of the reasonable accommodation process. If the exception is approved (and while

waiting for the approval decision), I acknowledge that I must follow the requirements and guidelines within the VA Notice,

Mandatory Coronavirus Disease 2019 (COVID-19) Vaccination Program for VA Employees,

• Wear a face mask;

• Physically distance;

• Submit to COVID-19 testing;

• Be subject to Government-wide travel restrictions on official travel; and

• Any other mitigation strategies required as part of the accommodation.

NOTE: Declaring an exception for a medical condition or religious exception requires the supervisor to engage in the reasonable

accommodation process in accordance with VA Handbook 5975.1 and VA Directive 5975.

Name (print):

Dept./Serv:

Employee Signature:

Date (MM/DD/YYYY):

VA employees provide this form to your supervisor.

Health Professions Trainees (HPTs) requesting medical or religious exceptions provide this form to the Designated Education Officer (DEO);

and proof of vaccination is provided to the DEO via the Trainee Qualifications and Credentials Verification Letter (TQCVL). HPTs who

request a medical or religious exception will follow the same reasonable accommodation process established for employees.

Privacy Act Statement:

Authority:

Pursuant to 5 U.S.C. chapters 11 and 79, and in discharging the functions directed under Executive Order 14043, Requiring Coronavirus

Disease 2019 Vaccination for Federal Employees (Sept. 9, 2021), we are authorized to collect this information. The authority for the system of

records notices (SORN) associated with this collection of information, OPM/GOVT-10, Employee Medical File System of Records,

75 Fed. Reg. 35099 (June 21, 2010), amended 80 Fed. Reg. 74815 (Nov. 30, 2015), for title 5 employees, and

08VA05, Employee Medical File System Records (Title 38)-VA, for title 38 employees, also includes 5 U.S.C. chapters 33 and 63 and

Executive Order 12196, Occupational Safety and Health Program for Federal Employees (Feb. 26, 1980). Providing this information is

mandatory, and we are authorized to impose penalties for failure to provide the information pursuant to applicable Federal personnel laws and

regulations.

Purpose

This information is being collected and maintained to promote the safety of Federal workplaces and the Federal workforce consistent with the

above-referenced authorities, Executive Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), the

COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force, and guidance from

Centers for Disease Control and Prevention and the Occupational Safety and Health Administration.

Routine Uses

While the information requested 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 SORNs associated with this

collection of information.

Consequence of Failure to Provide Information:

Providing this information is mandatory. Unless granted a legally required exception, all covered Federal employees are required to be

vaccinated against COVID-19 and to provide documentation concerning their vaccination status to their employing agency. Unless you have

been granted a legally required exception, failure to provide this information may subject you to disciplinary action, including and up to

removal from Federal service.

Certification

I sign this document under penalty of perjury that the above is true and correct, and that I am the person named above. 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). I understand that if I am a

Federal employee or contractor making a false statement on this form could result in additional administrative action, including an adverse

personnel action up to and including removal from my position or removal from a contract.

VA FORM 10230, page 2, JAN 2022