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Employee Vaccination Document Submission Form

  1. 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.  The City is gathering employee vaccination documentation data for all employees.  All information received shall 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 for Disease 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”.

    Please upload your vaccination documentation and complete the form below.   If you have any questions, please contact Human Resources directly by emailing or calling (510) 215-4315.  Thank you

  2. Please include both sides of the document.

  3. Employee Attest

    I attest that I am providing accurate information about my vaccination status and documentation. I hereby affirm that I have accurately and truthfully completed this form. 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 Documentation Submission Form, this signifies my signature.   

  4. By checking this box:*
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  6. This field is not part of the form submission.