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Employee Self-Certification of COVID-19 Vaccination Status Form

Author: XpertHR Editorial Team

When to Use

There are a variety of reasons an employer may have their employees complete a self-certification attesting whether they are vaccinated against COVID-19. For instance, employers who have a COVID-19 vaccination mandate as an additional measure to promote the health and safety of their employees and those who visit the workplace (e.g., customers, vendors) may use an employee's self-certification to determine their compliance with the mandate. On the other hand, employers may have employees complete the self-certification to determine exemption from certain COVID-19 safety measures, such as mask wearing or regular testing.

Also, jurisdictions may require certain employers to implement a vaccination mandate based on their industry, COVID-19 exposure risk or location. Employers covered under such federal, state or local orders are urged to determine the required information and procedures necessary to ensure compliance.

Employers that wish to determine the COVID-19 vaccination status of their employees may provide them with this form. This form also requests certain information regarding employees' vaccination status (e.g., dates of dose(s)) and advises employees where proof of vaccination is to be submitted.

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