Self-Certification of Vaccination Status
(Please input all fields marked with *)
Under Cal/OSHA’s June 17, 2021 revision to the Emergency Temporary Standard, businesses in California can allow fully vaccinated employees to work without masks indoors in most settings, but the employers must first document employees’ COVID-19 vaccination status.
In light of this requirement, please provide the information below. You are required to provide accurate information about your vaccination status, or you may decline to provide your vaccination status. If you decline to provide your vaccination status, we are required to assume you are unvaccinated for purposes of rules in the workplace that are different for vaccinated or unvaccinated employees. For example, because Cal/OSHA’s rules generally require unvaccinated employees to continue wearing masks indoors, the information collected below will be used to determine whether you will be required to wear a mask. Aside from complying with governmental requirements, no employee will be discriminated against based on his/her vaccination status, or response to the question below.
You are considered “fully vaccinated” two weeks after the second dose of a two-dose vaccine (e.g., Pfizer or Moderna), or two weeks after receiving a one-dose vaccine (e.g., Johnson & Johnson).
Check one:
My response to the above is truthful.
This document will be maintained in a secure manner, solely by the employer, to ensure the employee/member privacy is protected.
