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For the purpose of planning for the health and safety of employees and members of the public, employees are asked to provide information regarding their vaccination status and self-attest their status with the City. All information receivedshall be maintained by Human Resources and kept in the employee’s confidential medical file. An employee’s vaccination status shall only be used for safety planning purposes in accordance with the guidance provided by the Centers forDisease Control and Prevention (CDC) and state and local public health authorities, including the Cal/OSHA Emergency Temporary Standard and as outlined in the City’s guidance. Responses will be shared with the employee supervisor on a“need to know basis” and shall not be used in making decisions that could adversely affect employment.
Please complete the form below. If you have any questions, please contact Human Resources directly by emailing firstname.lastname@example.org or calling (510) 215-4315.
* I attest I am fully vaccinated, meaning I have received my second dose of a two dose COVID-19 vaccine (e.g. Pfizer or Moderna) OR I have received my single dose of a one-dose vaccine (e.g. Johnson & Johnson) two (2) or more weeks ago from today’s date. I understand that by being fully vaccinated, face coverings in most circumstances are optional, and I can still wear a face covering for comfort and safety should I choose to.
** At this time, I have chosen to not receive the vaccine and/or decline to state my vaccination status. I understand that I am considered unvaccinated and that I must continue to wear a face covering under most circumstances.
I attest that I am providing accurate information about my vaccination status. I hereby affirm that I have accurately and truthfully answered the question above. I authorize the disclosure and use of my vaccination status as described for the purposes listed above. I understand that this authorization is voluntary, and I am voluntarily signing this authorization. By completing and submitting the online version of the Employee Vaccination Status Self-Attest Form, this signifies my signature.
* indicates a required field