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COVID-19 Vaccine Status Attestation

Employee Name (print):

Please select the statement below that a describes your vaccination status:

I have received the COVID-19 vaccine (fully vaccinated).

I have received my first dose of Pfizer or Moderna, and my second appointment is scheduled.

I have not yet been vaccinated, but I have scheduled an appointment.

I decline to receive the COVID-19 vaccination for medical or religious reasons.

I decline to answer.

I hereby affirm that I have accurately and truthfully selected the response above that most closely represents my vaccination status. Further:

I understand that if I stated that I am fully vaccinated, my employer may request documentation of my vaccination status (i.e., a copy of my vaccine card or other similar documentation confirming vaccination status).
I understand that if I state that I decline to be vaccinated for medical or religious reasons, my employer may request additional documentation based on state and/or facility requirements.
I understand that if I state I decline to answer, my employer will assume this to mean that I am unvaccinated. Some facilities will require employees and contract staff to be fully vaccinated. Therefore, I understand and acknowledge that my vaccination status may affect my eligibility for employment with certain facilities.

My signature below indicates my acknowledgement and understanding of the above.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

February 28, 2023 4:58 pm EDT

COVID-19 Vaccine Status Attestation - Favorite Uploaded by Richard Williams - richard@assistms.com IP 104.128.161.76

February 28, 2023 5:14 pm EDT

Document owner richard@assistms.com has handed over this document to staff@assistms.com 2023-02-28 17:14:05 - 104.128.161.76