Los Angeles County Department of Public Health
3/26/21 Self-attestation (English)
Los Angeles County
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
I am employed as a: __________________________________________________________
Job Title
I work at: __________________________________________________________________
. School, Business, or Organization Name
. School, Business, or Organization Address
Signature: _____________________________________________
Name: ________________________________________________ Date: _____________________
If you do not have access to a printer, this attestation can be written by hand.