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Updated

Adoption Date: 01/11/2022

Revision History: 02/22/22 (reviewed), 12/13/22 (reviewed), 12/12/23 (reviewed)

I, ____________________ as an employee of the Iowa City Community School District do personally attest to the following:

1.    My vaccination status for COVID-19 is ________________ [fully vaccinated or partially vaccinated].

2.    To the best of my recollection, I can provide the following information about my vaccination status:  ___________________________ [type of vaccine administered, date(s) of administration, name of health care providers and clinic site]

3.    I have lost proof of my vaccination status and am otherwise unable to provide proof of my vaccination status.


4.    I declare that this statement about my vaccination status is true and accurate.  I understand that knowingly providing false information regarding my vaccination status on this form may subject me to criminal penalties.  

 

___________________________________                                                                  _____________________      

Employee                                                                                                                        Date

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