Employee Attestation of COVID-19 Vaccination Status

I, __________________________________ attest that I am ☐fully vaccinated / ☐partially vaccinated against COVID-19 and am unable to produce proof of vaccination.

I understand fully vaccinated to mean two weeks (14 days) have passed since receiving either a one-dose vaccine or a second dose of a two-dose vaccine; and partially vaccinated means a second dose must still be obtained and/or two weeks have not passed since my final dose.

Type of vaccination received:

• Johnson & Johnson
  
• Moderna
• Pfizer-BioNTech
• Other: __________________________

Dates of vaccine administration: First dose: ___/ ___/ ____        Second dose: ___/ ___/ ____

Name of health care professional or clinic administering the vaccine: 

_______________________________________________________________________

Additional comments:

____________________________________________________________________________________________________________________________________________________

I declare [or certify, verify, or state] that this statement about my vaccination status is true and accurate. I understand that knowingly providing false information regarding my vaccination status on this form may subject me to criminal penalties.

_________________________________________                              ___________________

Signature                                                                                                       Date

_________________________________________

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