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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Eligibility Category

Name

Nombre

Apellido

Email

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Date Today

Date of Birth

Gender

Female Male Prefer not to say

Name of Organization Where Employed

Your Position

Address of Organization

Dirección

Ciudad

Estado / Provincia

Código postal

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

Nombre

Apellido

Signature

Sign here

Date

COVID-19 Vaccine Self-Certification Form

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