COVID-19 Vaccine Self-Certification Form

Lets an applicant self-certify that they meet the medical eligibility criteria to receive the COVID-19 vaccine.

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In the Claude connectors directory

Eligibility Category

Name

First Name

Last Name

Email

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Date Today

Date of Birth

Gender

Female Male Prefer not to say

Name of Organization Where Employed

Your Position

Address of Organization

Street Address

City

State / Province

ZIP / Postal Code

Medical Condition Declaration

I declare that I have been diagnosed by a qualified physician, who is not a family member, with at least one of the following medical conditions that increase my risk of severe illness from COVID-19.

Diabetes Heart disease Chronic lung disease Obesity Chronic kidney disease Immunocompromising condition

Certification Statement

Name

First Name

Last Name

Signature

Sign here

Date

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