I, __________________________________ attest that I am ☐fully vaccinated / ☐partially vaccinated against COVID-19 and am unable to produce proof of vaccination.
I understand fully vaccinated to mean two weeks (14 days) have passed since receiving either a one-dose vaccine or a second dose of a two-dose vaccine; and partially vaccinated means a second dose must still be obtained and/or two weeks have not passed since my final dose.
Type of vaccination received:
Dates of vaccine administration: First dose: ___/ ___/ ____ Second dose: ___/ ___/ ____
Name of health care professional or clinic administering the vaccine:
I declare [or certify, verify, or state] that this statement about my vaccination status is true and accurate. I understand that knowingly providing false information regarding my vaccination status on this form may subject me to criminal penalties.