Fillable Sample Personnel Vaccination Program Ascertainment Form (Revised August

Fill Online, Printable, Fillable, Blank Sample Personnel Vaccination Program Ascertainment Form (Revised August Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Sample Personnel Vaccination Program Ascertainment Form (Revised August

On average this form takes 7 minutes to complete

The Sample Personnel Vaccination Program Ascertainment Form (Revised August form is 6 pages long and contains:

  • 0 signatures
  • 10 check-boxes
  • 24 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Sample Personnel Vaccination Program Ascertainment Form
(Revised August 12, 2021)
1
NOTE: This sample form is provided by way of example and is not legal advice to any Business.
Any Business that implements a vaccination program should consult its own legal counsel
regarding the content of any such program. But, as outlined by Sections 4, 6, and Appendix B to
Health Officer Order No. C19-07y (including as that order is updated in the future), the required
vaccination program for Personnel in High Risk Settings, Personnel in certain additional health
care settings, and staff at certain indoor Businesses must include ascertainment of vaccination
status addressing the issues included in this sample form.
COVID-19 MANDATORY VACCINATION
DISCLOSURE FORM
As stated in Sections 4, 6, and Appendix B to Health Officer Order No. C19-07y (including as
that order is updated in the future), all Personnel or staff who work in High Risk Settings, certain
additional health care settings, and certain indoor Businesses in the City and County of San
Francisco are required to be fully vaccinated for COVID-19. As noted by the United States
Equal Employment Opportunity Commission and California Department of Employment and
Fair Housing, any person who has either (1) a medical condition or disability that prevents taking
the vaccine or (2) a sincerely held religious belief, practice, or observance that prevents the
person from taking the vaccine may be entitled to a reasonable accommodation.
1
Under Order
C19-07, operators of these businesses must ascertain the vaccination status of all Personnel or
staff and may be required to allow Personnel or staff who meet the criteria for exemption to
decline the mandatory vaccination and instead follow the mandatory requirements for
unvaccinated individuals listed in the Order (which include wearing a Well-Fitted Mask at all
times other than when actively eating or drinking and being Tested weekly—refer to the Order
for specific requirements and a Sample Employee Declination Form found at
www.sfdph.org/dph/alerts/files/C19-07-Safer-Return-Together-Health-Order.pdf).
Directions: All Personnel or staff must complete Section 1 (Disclosure of Vaccination Status)
below unless the business operator otherwise obtains the required information, and anyone
completing Section 1 must also complete Section 2 (Signature).
1
For more information, see www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-
ada-rehabilitation-act-and-other-eeo-laws and www.dfeh.ca.gov/wp-
content/uploads/sites/32/2020/03/DFEH-Employment-Information-on-COVID-19-
FAQ_ENG.pdf.
Sample Personnel Vaccination Program Ascertainment Form
(Revised August 12, 2021)
2
Section 1 – Disclosure of Vaccination Status
[All Personnel or staff must complete this Section]
Each operator of a High Risk Setting and certain additional health care and indoor business
settings in the City and County of San Francisco is required by Health Officer Order No. C19-07
to ascertain the vaccination status of all Personnel (including employees, contractors, and
volunteers) or, where applicable, staff who routinely work onsite, and all such Personnel or staff
are required to disclose their vaccination status. Please complete this section in order to provide
your vaccination status. This information must be kept confidential by the entity consistent with
privacy laws. Check only one box in this section:
☐ I want to be vaccinated. I have not yet received a vaccine for COVID-19 and wish to get
information about becoming vaccinated. I understand that I will need to update this form
once my vaccination is complete, and until then I will be required to comply with the
conditions for Personnel who are not Fully Vaccinated. More information about
vaccination is available online at sf.gov/covid-19-vaccine-san-francisco.
☐ I am in the process of being vaccinated. I have started the process of receiving a
vaccine/vaccine series for COVID-19. Until two weeks after the final dose, I understand
that I will be required to comply with the conditions for Personnel who are not Fully
Vaccinated and that I will need to update this form once my vaccination is complete.
The date when I expect to be fully
vaccinated (2 weeks after the final dose) is:
☐ I am Fully Vaccinated. I have completed my COVID-19 vaccination process. Below is
the information about my vaccination series:
My date of birth:
Vaccine manufacturer:
☐ Johnson & Johnson/Janssen (1 dose)
☐ Moderna (2 doses)
☐ Pfizer (2 doses)
☐ Other (list manufacturer):
Date(s) of vaccine administration (list date
of first dose and, if applicable, second dose):
☐ I decline to be vaccinated and am eligible for an exemption. I do not wish to be
vaccinated and meet one of the two criteria for vaccination exemption in Health Officer
Order C19-07. I understand that I will be required to comply with the conditions for
Personnel or staff who are not Fully Vaccinated unless or until I am able to be fully
vaccinated. Please note: employees who choose this option must refer to the Order for
specific requirements and a Sample Employee Declination Form found at
www.sfdph.org/dph/alerts/files/C19-07-Safer-Return-Together-Health-Order.pdf. All
required forms – including where applicable a signed Healthcare Provider Supporting
Statement – must be provided before a request for declination is considered complete.
Personnel are considered out of compliance with the vaccination program if they fail to
completely fill out, sign, and submit all applicable forms and documents.
Sample Personnel Vaccination Program Ascertainment Form
(Revised August 12, 2021)
3
Section 2 – Signature and Attestation
[All Personnel or staff who complete any section of this form must complete this Section]
I declare under penalty of perjury under the laws of the State of California that the statement(s)
in Section 1 above are true and correct.
Signature:
Date:
Printed name:
Location (City and State) where signed:
1
Sample Personnel Vaccination Program Declination Form
(Revised August 12, 2021)
NOTE: This sample form is provided by way of example and is not legal advice to any Business.
Any Business that implements a vaccination program should consult its own legal counsel
regarding the content of any such program. But, as outlined by Sections 4, 6, and Appendix B to
Health Officer Order No. C19-07y (including as that order is updated in the future), the required
vaccination program for Personnel in High Risk Settings, Personnel in certain additional health
care settings, and staff at certain indoor Businesses must include ascertainment of vaccination
status and providing a declination option addressing the issues included in this sample form.
COVID-19 MANDATORY DECLINATION FORM
As stated in Sections 4, 6, and Appendix B to Health Officer Order No. C19-07y (including as
that order is updated in the future), all Personnel or staff who work in High Risk Settings, certain
additional health care settings, and certain indoor Businesses in the City and County of San
Francisco are required to be fully vaccinated for COVID-19. As noted by the United States
Equal Employment Opportunity Commission and California Department of Employment and
Fair Housing, any person who has either (1) a medical condition or disability that prevents taking
the vaccine or (2) a sincerely held religious belief, practice, or observance that prevents the
person from taking the vaccine may be entitled to a reasonable accommodation.
1
Under Order
C19-07, operators of these businesses must ascertain the vaccination status of all Personnel or
staff and must allow Personnel or staff who meet the criteria for exemption to decline the
mandatory vaccination and instead follow the mandatory requirements for unvaccinated
individuals listed in the Order (which include wearing a Well-Fitted Mask at all times other than
when actively eating or drinking and being Tested weekly—refer to the Order for specific
requirements).
Directions: All Personnel or staff must complete a separate Disclosure of Vaccination Status
(found at www.sfdph.org/dph/alerts/files/C19-07-Safer-Return-Together-Health-
Order.pdf) unless the business operator otherwise obtains the required information. Any
Personnel or staff seeking to decline vaccination must also complete Section 1 (Vaccine
Declination) and Section 2 (Signature) of this form. Please note: Personnel and staff
who choose the declination option must fill out all applicable forms. All required forms –
including, where applicable a signed Healthcare Provider Supporting Statement – must be
provided before a request for declination is considered complete. Personnel and staff are
considered out of compliance with the vaccination program if they fail to completely fill
out, sign, and submit all applicable forms and documents.
1
For more information, see www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-
ada-rehabilitation-act-and-other-eeo-laws and www.dfeh.ca.gov/wp-
content/uploads/sites/32/2020/03/DFEH-Employment-Information-on-COVID-19-
FAQ_ENG.pdf.
2
Sample Personnel Vaccination Program Declination Form
(Revised August 12, 2021)
Section 1 –Vaccine Declination
[All Personnel or staff seeking an exemption from vaccination must complete this Section]
By completing this Section 1, I am declaring that I am unable to be vaccinated for COVID-19 on
the following basis (check all that apply):
☐ Medical/Disability Accommodation: I have a medical condition or disability that
prevents me from being able to take any COVID-19 vaccine. NOTE: To be eligible for
this exemption, I understand that I must also provide to my employer (or the Business
where I work or volunteer) a written statement signed by a physician, nurse
practitioner, or other licensed medical professional practicing under the license of a
physician, stating that I qualify for the exemption (but the written statement should not
describe the underlying medical condition or disability) and indicating the probable
duration of my inability to receive the vaccine (or if the duration is unknown or
permanent, so indicate). I may use the next page of this form for that purpose.
☐ Religious Belief Accommodation: I have a sincerely held religious belief, practice, or
observance that prevents me from taking any of the FDA authorized or approved
COVID-19 vaccines.
Section 2 – Signature and Attestation
[All Personnel or staff who complete any section of this form must complete this Section]
I declare under penalty of perjury under the laws of the State of California that the statement(s)
in Section 1 above are true and correct.
Signature:
Date:
Printed name:
Location (City and State) where signed:
3
Sample Personnel Vaccination Program Declination Form
(Revised August 12, 2021)
COVID-19 MANDATORY VACCINATION DECLINATION
Healthcare Provider Supporting Statement
In order for a person who works, provides services, or volunteers in High Risk Settings, certain
additional health care settings, and certain indoor businesses in the City and County of San
Francisco to qualify for a Medical/Disability Accommodation to the requirement to receive a
COVID-19 vaccination, their healthcare provider (only a physician, nurse practitioner, or other
licensed medical professional practicing under the license of a physician) must complete the
following form to be provided by the person to their employer or other Business location where
they work or volunteer. NOTE – Do not state that nature of the underlying medical condition or
disability.
Name of person seeking
a medical/disability exemption:
Date of birth of person seeking exemption:
Name of physician, nurse practitioner, or
other licensed medical professional
practicing under the license of a physician:
Anticipated duration of medical condition/disability
(or indicate if the duration is unknown or permanent):
By completing and signing this form, I certify that my client/patient listed above should not
receive the COVID-19 vaccine due to (explain the specific contraindication to vaccination here,
but do not identify the underlying medical condition or disability – attach a separate sheet or
statement if necessary):
__________________________________________________________________________
__________________________________________________________________________
I certify the above information to be true and accurate, and I request exemption from the
COVID-19 vaccination for the above-named individual.
Signed by:
Dated:
License number:
Contact info (address and telephone number):
If practicing under the license of a physician,
name and license number of physician:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Sample Personnel Vaccination Program Ascertainment Form (Revised August

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document