403.7E1 - Employee Personal Attestation of Vaccination Status

 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