EMPLOYEE PERSONAL ATTESTATION OF VACCINATION STATUS

 

I, ____________________ as an employee of the District do personally attest to the following:

1.      My vaccination status for COVID-19 is ________________ [fully vaccinated or partially vaccinated].

2.      To the best of my recollection, I can provide the following information about my vaccination status:  ___________________________ [type of vaccine administered, date(s) of administration, name of health care providers and clinic site]

3.      I have lost proof of my vaccination status and am otherwise unable to provide proof of my vaccination status.

4.      I declare 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. 

 

 

 

___________________________________                           ________________________

Employee                                                                                Date

 

 

MEDICAL ACCOMMODATION REQUEST FORM

(1)     What is the basis for the medical accommodation that you are requesting?

(2)     What are you requesting an accommodation from?

 

 

___________________________________              ________________________________

Employee Signature                                                                Date

 

 

 

---

 Office Use

This request has been:

 ______________________________                        ________________________________

Approved                                                                                Denied

 

_________________________________                  ______________________________

Administrator                                                                          Date

 

RELIGIOUS ACCOMMODATION REQUEST FORM

 

(1)     Please identify the policy requirement or practice that conflicts with your sincerely held religious observance, practice or belief:

 

 

(2)     Please describe the nature of your sincerely held religious beliefs or religious practice or observance that conflict with the policy or practice you have identified above:

 

 

(3)     What are you requesting an accommodation from?

 

  

___________________________________              ________________________________

Employee Signature                                                                Date

 

 

---

Office Use

 

This request has been: 

______________________________                        ________________________________

Approved                                                                                Denied

 

__________________________________                ______________________________

Administrator                                                                          Date

 

Acceptable Proof of Vaccination Status
To satisfy the vaccination requirement within this policy, employees must submit to the Superintendent or Superintendent’s designee acceptable proof of vaccination status no later than December 6, 2021.  Acceptable proof of vaccination status includes:

1. Immunization records from a healthcare provider or pharmacy;
2. A copy of a COVID-19 Vaccination Record Card;
3. A copy of medical records documenting immunization;
4. A copy of immunization records from a public health, state or tribal immunization information system;
5. Any other official documentation that contains the type of vaccine administered, dates of administration, and the name of the administering health provider or clinic;
6. If any other records are unavailable a signed and dated personal attestation statement.

Any employee who fails to provide acceptable proof of vaccination status may face disciplinary action up to and including termination.

Record Keeping
The district is required by law to keep a roster of the vaccination status of all employees. Any records showing proof of employee vaccination status the district maintained prior to November 5, 2021 will be considered sufficient proof of the employee’s vaccination status.

Any records related to an employee’s vaccination status, including the employee vaccination status roster, will be considered confidential employee medical records not subject to public disclosure and stored as employee medical records consistent with law.  These records will be maintained by the district for as long as 29 C.F.R. 1910.501 remains in effect.

Testing
Beginning January 4, 2022, employees who are not fully vaccinated must submit proof of negative COVID-19 test results every 7 days.  Documentation of negative test results must be provided to the district no later than every 7 days.  Employees who are not fully vaccinated and do not report to work for longer than 7 days (ex. an employee on vacation or on leave) must provide documentation of a negative test result upon their return to work.  If the employee fails to provide proof of a negative test result, the district must keep the employee removed from the workplace until the negative test result documentation is provided.

Employees who receive a positive COVID-19 test result or have been diagnosed with COVID-19 by a licensed healthcare provider; are not required to produce another test result for 90 days from the date of their positive result.  

Positive Test Results
Regardless of vaccination status, employees must report any positive COVID-19 test results or a diagnosis of COVID-19 by a licensed healthcare provider to the district.  Any employee so reporting will be immediately removed from the workplace and will stay removed from the workplace until any of the following occur:

• The employee receives a negative result on a COVID-19 nucleic acid amplification test (NAAT) following a positive result on a COVID-19 antigen test if the employees chooses to seek the confirmatory test
• The employee meets the return to work criteria in the CDC’s “Isolation Guidance” listed here: https://www.cdc.gov/coronavirus/2019-ncov/your-health/quarantine-isolation.html
• The employee receives a recommendation to return to work from a licensed healthcare provider.

New Employees
New employees will be subject to the provisions of this policy upon hire as soon as practicable.  Within 7 days of hire, new employees will provide proof of their vaccination status to the district in accordance with the requirements of this policy.  Unless fully vaccinated, new employees will abide by the testing and face-covering requirements of this policy within 7 days of hire.  

Leave
As required by 29 C.F.R. 1910.501, the district will provide up to 4 hours of paid leave to cover the time required to travel to and obtain each dose of the primary vaccination for COVID-19.  If additional time is required, the employee may use other accrued leave available.  The district will also provide reasonable paid sick leave to employees to recover from any effects of each primary dose of COVID-19 vaccine.  The district may require employees to use previously accrued paid sick leave first.

Employees Excluded
Employees who work fully remote from the job site; employees working from home; and employees who work exclusively outdoors are excluded from the vaccination, testing and face-covering requirements of this policy.  Employees fully remote from the job site does not include employees whose work requires them to work off-site from the district but in the presence of students or employees of the district.  Employees who work exclusively outdoors means those individuals who do not spend any part of their work time indoors.

Face Coverings
Beginning December 5, 2021, face coverings must be worn by all employees who have not provided proof of full vaccination status to the district.  Face coverings will be worn when employees are working indoors, in vehicles or other enclosed spaces.  Face coverings are not required to be worn when employees are: working alone in a room with floor to ceiling walls and a closed door; verifying identity for security purposes or eating/drinking; when an employee is wearing a respirator or facemask; or where the district can show that the use of a face covering is infeasible or creates a greater hazard.  The face-covering must fully cover the employee’s nose and mouth; and be replaced when wet, soiled or damaged.

Reporting Requirements of the District
The district will report to OSHA:

• Each work-related COVID-19 fatality within 8 hours of the employer learning about the fatality;
• Each work-related COVID-19 inpatient hospitalization within 24 hours of the employer learning about the inpatient hospitalization.

The district will report to individual employees or anyone having written authorized consent of the employee by the end of the next business day after the request is made:

• Documentation of any COVID-19 test results for that employee;
• The aggregate number of fully vaccinated employees at a workplace along with the total number of employees at that workplace.

The district will provide to the Assistant Secretary of Labor for Occupational Safety and Health, U.S. Department of Labor, or their designee:

• A copy of this policy, and the aggregate number of fully vaccinated employees at a workplace along with the total number of employees at that workplace, to be provided within 4 business hours of the request being made; and
• All other records and supporting documents related to this policy by the end of the next business day of the request being made.
   

For additional information on COVID-19 vaccine efficacy, safety, and the benefits of being vaccinated, please consult the following document “Key Things to Know About COVID-19 Vaccines” https://www.cdc.gov/coronavirus/2019-ncov/vaccines/keythingstoknow.html

 29 C.F.R. 1904.34(b)(1)(iv) prohibits the employer from discharging or in any manner discriminating against an employee for reporting a work-related injury or illness.

11(c) of the Occupational Safety and Health Act prohibits the employer from discriminating against an employee for exercising rights under, or as a result of actions that are required by, this policy.  11(c) also protects employees from retaliation by the employer for filing an occupational safety or health complaint, reporting a work-related injury or illness, or otherwise exercising any rights provided by the OSH Act. 

18 U.S.C. 1001 and section 17(g) of the OSH Act provide for criminal penalties associated with knowingly supplying false statements or documentation in accordance with this policy.