COVID-19 Vaccine Status Attestation


Employee Name (print):  


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


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:

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Signature Certificate
Document name: COVID-19 Vaccine Status Attestation - Favorite
lock iconUnique Document ID: ac220a8966ff127559c6777d35afa87327eb434a
Timestamp Audit
February 28, 2023 4:58 pm EDTCOVID-19 Vaccine Status Attestation - Favorite Uploaded by Richard Williams - IP
February 28, 2023 5:14 pm EDT Document owner has handed over this document to 2023-02-28 17:14:05 -