COVID VACCINE ATTESTATION

Please answer the following questions regarding the COVID-19 Vaccine. Please note that these questions are for information gathering purposes only, the vaccine is not required at this time.
Have you received your FIRST DOSE of the COVID-19 Vaccine?*
- YES
- NO
Date you received FIRST COVID Vaccine:*
MM slash DD slash YYYY
Have you received your SECOND DOSE of the COVID-19 Vaccine?*
- YES
- NO
Date you received SECOND COVID Vaccine:*
MM slash DD slash YYYY
Please check the box below that reflects your current status regarding the COVID-19 vaccine.*
- I am interested in the vaccine however do not have a scheduled appointment.
- I have been offered the COVID vaccine. I decline and do not want to receive the vaccine at this time.
Your Name (ABC Employee)*
First Last
Consent*
I hereby acknowledge that I have read, understand and consent to the above statements.
Signature: I understand that the COVID vaccine is voluntary. I certify that the information provided by me in this attestation is true and accurate as of this date.
Signature*
Today's Date*
MM slash DD slash YYYY
CAPTCHA