Fillable COVID-19 VACCINE ELIGIBILITY: Self-Attestation (County of Los Angeles / Internal Services Department)

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COVID-19 VACCINE ELIGIBILITY: Self-Attestation (County of Los Angeles / Internal Services Department)

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The COVID-19 VACCINE ELIGIBILITY: Self-Attestation (County of Los Angeles / Internal Services Department) form is 1 page long and contains:

  • 0 signatures
  • 4 check-boxes
  • 7 other fields

Country of origin: US
File type: PDF

U.S.A. forms for County of Los Angeles / Internal Services Department

BROWSE COUNTY OF LOS ANGELES / INTERNAL SERVICES DEPARTMENT (CA) FORMS

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Los Angeles County Department of Public Health
www.VaccinateLACounty.com
3/26/21 Self-attestation (English)
Los Angeles County
COVID-19 VACCINE ELIGIBILITY: Self-Attestation
I attest that (check only one box):
I have a medical condition or disability that makes me eligible for the COVID-19 vaccine
I am experiencing homelessness in Los Angeles County and currently stay in a shelter or may
transition into a shelter or congretate living setting
I live or work in a high risk congregate setting: _________________________________________
Facility Name
_________________________________________________________________________________
Facility Address
I work in one of the following sectors (please check one and fill in the information below):
o in the Education and Childcare sector
o onsite in the Healthcare sector
o onsite in the Emergency Services sector
o onsite in the Food and Agriculture sector
o onsite in the Janitorial/Custodial/Maintenance Service sector
o onsite in the Transportation and Logistics sector
o As a caregiver for over 20 hours a week
And
I am employed as a: __________________________________________________________
Job Title
I work at: __________________________________________________________________
. School, Business, or Organization Name
__________________________________________________________________
. School, Business, or Organization Address
Signature: _____________________________________________
Name: ________________________________________________ Date: _____________________
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COVID-19 VACCINE ELIGIBILITY: Self-Attestation (County of Los Angeles Internal Services Department)

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Completed 5 April 2021

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