Self-Certification of Vaccination Status

Self-Certification of Vaccination Status
Employer/Business/Entity Name:*
Employee First Name:*
Employee Last Name:*
Date of Birth:*
MonthDayYear
Date
Under the Health Officer’s May 18, 2021 Order, all businesses and governmental entities in Santa Clara County are required to determine the COVID-19 vaccination status of their employees (as well as contractors, volunteers, and others who regularly work onsite). In light of this requirement, you must provide the information requested below.
Please note that you are required to provide accurate information about your vaccination status in response to the questions below, or alternatively may decline to provide your vaccination status. If you decline to provide information about your vaccination status, we will be required to assume you are unvaccinated for purposes of rules or requirements in the workplace that are different for vaccinated or unvaccinated employees. For example, if requirements on face coverings allow fully vaccinated employees not to wear face coverings in certain settings, the information collected below will be used to determine whether you will be required to wear a face covering in those settings.
For purposes of this certification, you are considered “fully vaccinated” two weeks after completing the second dose of a two-dose COVID-19 vaccine (e.g., Pfizer or Moderna) or two weeks after receiving a single dose of a one-dose vaccine (e.g., Johnson & Johnson/Janssen).
Please select the statement below that accurately describes your vaccination status:*
I am fully vaccinated.I received my second dose of the Pfizer or Moderna vaccine or my single dose of a Johnson & Johnson vaccine less than two weeks ago.I received my first dose of Moderna or Pfizer, and my second appointment is scheduled.I have not yet been vaccinated, but I have already scheduled an appointment to receive my first dose of vaccine.I have not been vaccinated.I decline to answer whether I have been vaccinated.
I understand that I am required to provide accurate information in response to the question above. I hereby affirm that I have accurately and truthfully answered the question above. I also understand that if I stated that I am fully vaccinated, my employer may request documentation of my vaccination status (e.g., a copy of my vaccine card or other similar official document confirming vaccination status).
Signature*
Clear
Date*
MonthDayYear
Date
Should be Empty: