COVID-19 Vaccine Self-Certification Form

COVID-19 Vaccine Self-Certification Form
Due to the limited availability of COVID-19 vaccines, we have set prioritization for vaccine distribution to frontliners and to those who have a high risk of exposure to COVID-19 infection due to their duties and responsibilities in the workplace.
The purpose of this self-certification form is to offer to those who are qualified medical staff to receive COVID-19 vaccination. Please take note that filling out this form and the receiving of a vaccine against COVID-19 is voluntary. Thus, if you wish not to receive a COVID-19 vaccine, there is no need to fill out this form. However, as mentioned that due to the limited supply of the vaccine, there is the possibility that not everyone may have the chance to receive the vaccine.
Your privacy is important to us. We will not share any of your personal information without your consent other than what is necessary for processing your information in this matter.
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date Today
MonthDayYear
Date
Date of Birth
MonthDayYear
Date
Age
Gender
Name of Organization Where Employed
Your Position
Address of Organization
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
CERTIFICATION
I hereby declare that I have been diagnosed and by a qualified medical physician, who is not a family member with at least one of the following medical conditions, and by which increases my risk for a severe illness that may be caused by COVID-19.
I hereby declare that I am at least 18 years of age and certify that the information I have provided herein is true and correct to the best of my knowledge. I understand that the submission of this form is voluntary and I have not been compelled, coerced, or intimidated in any way to submit this request. I understand that any false, misleading, or deliberate intent to commit fraud in this certification may subject me to disciplinary action.
Name
First NameLast Name
Signature
Clear
Date
MonthDayYear
Date
Should be Empty: