State of Delaware
Department of Human Resources
Certification of COVID-19 Vaccination Status FINAL 9.7.21 1 | P a g e
Employee Name: ___________________________________________ Employee ID: ___________________
Department: _______________________________________________
Division/Section: ____________________________________________
I certify that I am fully vaccinated against COVID-19 ☐ Yes ☐ No
Note: Fully vaccinated is defined as two weeks following a single-dose vaccine or two weeks following the 2
nd
dose of a two-dose vaccine.
If you answered no, you are required to complete weekly COVID-19 testing and submit the COVID-19 Testing
Certification Form.
Vaccine Manufacturer:
☐ Johnson & Johnson ☐ Moderna ☐ Pfizer ☐ Other: _________________________
Date(s) of Dose(s): 1
st
dose: _________________ 2
nd
dose: _________________
I understand that the State is seeking my COVID-19 vaccination status in order to ensure that my workplace
maintains an acceptable health and safety standard for my co-workers and visitors to the State's workspace,
that I am required to provide accurate information in response to the questions above, and that failure to do so
may result in disciplinary action. I certify that I have accurately and truthfully answered the questions above.
I understand that the Department of Human Resources may request documentation of my vaccination status
(e.g. a copy of my vaccine card, immunization record). I understand that failure to provide documentation of full
vaccination status upon request may result in disciplinary action.
I understand that any additional documentation or other confirmation of vaccination provided by me to my
employer (the State of Delaware) is considered medical information and will be kept in a confidential medical
file.
By using this form, the parties acknowledge their agreement to conduct transactions by electronic means. A
party’s electronic signature for purposes of the Uniform Electronic Transactions Act, 6 Del. C. Ch. 12A, may be
provided by electronic initials or name, or e-mail confirmation. Authorizations provided on this form will expire
one (1) year from the date submitted.
_________________________________ _______________________
Employee Signature Date
PLEASE SUBMIT COMPLETED FORM TO CovidCert@delaware.gov
This policy is not intended to create any individual right or cause of action not already existing and recognized
under State and Federal law.
COVID-19 VACCINATION CERTIFICATION FORM
Form #: COVID-19 Temporary Statewide Form
Authority: State of Delaware Declaration of a
Public Health Emergency July 12, 2021; 20
Del. C. Chapter 3137
Effective: September 1, 2021
PLEASE DO NOT INCLUDE VACCINATION CARD OR OTHER VACCINATION RECORDS UNLESS REQUESTED.
