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From: Secretary Teller (DOT) Secretary_Tesler@dot.state.ma.us Sent: Wednesday, October 13, 2022 3:23 PM To: DOWNFALL DOTDLALL@dot.state.ma.us Subject: Vaccine Mandate Implementation Update Attestations

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How to fill out employee-covid-19-vaccination-self-attestation-form

01

Obtain the employee-covid-19-vaccination-self-attestation-form.

02

Write your personal information such as name, employee ID, and contact details in the specified fields.

03

Mark the checkboxes indicating your vaccination status (fully vaccinated, partially vaccinated, not vaccinated).

04

If you are fully or partially vaccinated, provide details about the vaccines you have received, such as the name of the vaccine, dates of doses, and the provider.

05

If you are not vaccinated, you may need to provide a reason or explanation.

06

Sign and date the form to acknowledge that the information provided is truthful and accurate.

07

Submit the completed form to the designated authority or department.

Who needs employee-covid-19-vaccination-self-attestation-form?

01

Employees who are required to disclose their COVID-19 vaccination status.

02

Employers who need to collect and maintain records of their employees' vaccination status.

03

Employers or authorities who implement COVID-19 safety protocols and policies.

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What is employee-covid-19-vaccination-self-attestation-form?

Employee-covid-19-vaccination-self-attestation-form is a form where employees self-attest their COVID-19 vaccination status.

Who is required to file employee-covid-19-vaccination-self-attestation-form?

All employees are required to file the employee-covid-19-vaccination-self-attestation-form.

How to fill out employee-covid-19-vaccination-self-attestation-form?

Employees can fill out the form by providing their personal information and confirming their vaccination status by signing and dating the form.

What is the purpose of employee-covid-19-vaccination-self-attestation-form?

The purpose of the form is to collect information about employees' COVID-19 vaccination status for record-keeping and compliance purposes.

What information must be reported on employee-covid-19-vaccination-self-attestation-form?

Employees must report their name, employee ID, vaccination status, date of vaccination, and any supporting documentation.

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