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