Los Angeles County Department of Public Health
www.VaccinateLACounty.com
/16/21 Self-attestation (English)
COVID-19 Vaccine
Self-Attestation of eligibility for additional dose
This form is for people who have a moderately to severely weakened immune system who
have already received 2 doses of Pfizer or Moderna COVID-19 vaccine.
_________________
If you meet the criteria outlined by the CDC, it is recommended that you get a 3
rd
dose of an mRNA
(Pfizer or Moderna) vaccine at least 28 days after your 2
nd
dose of vaccine. When possible, you should
receive the same vaccine. For example, if you got a series of Pfizer vaccine, try to get a Pfizer vaccine
for your 3
rd
dose.
Talk to your doctor about the need to get an additional dose of COVID-19 vaccine. If you need
a 3rd dose, ask about the best timing based on your current treatment plan. This is especially
important if you are about to start or restart immunosuppressive treatment.
I attest that I am immunocompromised and am eligible for a third dose of vaccine based
on the criteria below.
• Receiving active cancer treatment for tumors or cancers of the blood;
• Received an organ transplant and am taking medicine to suppress my immune system;
• Received a stem cell transplant within the last 2 years or am taking medicine to suppress
the immune system;
• Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-
Aldrich syndrome);
• Advanced or untreated HIV infection;
• Active treatment with high-dose corticosteroids or other drugs that suppress my immune
response
Signature: _____________________________________________
Name: ________________________________________________ Date: _____________________
It is important to continue to protect yourself after you get a 3
rd
dose of vaccine. This includes
wearing a well-fitting mask, maintaining physical distance, avoiding crowded places or spaces with
poor air flow, and washing hands often. Consider “double masking” (wearing a cloth face mask over
surgical mask) or an N95 respirator for a higher level of protection.
For more information, see the Moderna or Pfizer Fact Sheets for Recipients and Caregivers
and the CDC webpage COVID-19 Vaccines for Moderately to Severely Immunocompromised
People.
If you do not have access to a printer, you can write the attestation by hand.
