COVID-19 Vaccination Attestation Form Template

A comprehensive vaccination attestation form that helps organizations document employee vaccination status, maintain compliance, and ensure workplace safety. Designed for HR professionals and business owners.

COVID-19 Vaccination Attestation Form

A COVID-19 vaccination attestation form is an official document used to record and verify an individual's vaccination status. This legally-compliant template helps organizations maintain accurate records while protecting employee privacy and ensuring workplace safety protocols.

What This Template Is For

This attestation form serves as a formal declaration of an employee's COVID-19 vaccination status when direct proof of vaccination cannot be provided. It includes essential elements such as vaccination type, dates, and legal declarations to ensure accuracy and accountability.

When To Use This Template

Use this template when:

  • Implementing workplace vaccination policies
  • Recording employee vaccination status
  • Managing return-to-office protocols
  • Documenting vaccination status for compliance purposes
  • Maintaining health and safety records

How To Customize It

Follow these steps to customize the attestation form:

  1. Add your organization's logo and letterhead
  2. Include specific policy references and requirements
  3. Adjust the vaccination type options based on approved vaccines in your region
  4. Modify the legal declaration language according to local requirements
  5. Add any additional fields required by your organization

Common Use Cases

This template is commonly used by:

  • Human Resources departments
  • Healthcare facilities
  • Educational institutions
  • Government agencies
  • Private businesses implementing vaccination policies

Best Practices

  • Keep language clear and straightforward
  • Include precise definitions of vaccination status
  • Maintain confidentiality of completed forms
  • Store documents securely
  • Update forms as vaccination guidelines change

Template Variations

Available variations include:

  • Simple attestation form
  • Detailed medical history version
  • Multi-language formats
  • Digital submission forms

Success Stories

Organizations report successful implementation for:

  • Safe return-to-office transitions
  • Healthcare facility compliance
  • Educational institution safety protocols
  • Government agency requirements

Frequently Asked Questions

Is this attestation form legally binding?

Yes, when properly completed and signed, this form serves as a legal declaration of vaccination status.

How long should attestation forms be kept on file?

Forms should be retained according to your organization's document retention policy, typically for at least one year.

Can employees update their attestation form?

Yes, employees can submit updated forms as their vaccination status changes.

Is this form HIPAA compliant?

Yes, when properly handled and stored, this form meets HIPAA privacy requirements.

Can this form be used for booster shots?

Yes, the form can be modified to include booster shot information.