1. Read and fill out this form completely and hit the submit button
  2. Email a copy of your vaccine card to: and

Declaration Attesting to the Authenticity of an Individual’s CDC COVID-19 Vaccination Card

Pursuant to Executive Order No. 138, a long-term care facility shall ensure individuals with direct access to a patient or resident of a long-term care facility are fully vaccinated against COV ID-19, partially vaccinated by September 7, 2021, or exempted from the vaccine requirement for medical or religious reasons. Individuals submitting a CDC vaccination card to verify their vaccine status must also include a declaration attesting that the card is authentic.

If you are using a CDC vaccination card to verify your vaccine status, please complete this declaration form and submit it to the individual(s) designated by the facility to receive these forms.