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Coachella Valley Unified School District
Certification of Vaccination Form
3/29/2023

Coachella Valley Unified School District
Certification of Vaccination

As part of the Coachella Valley Unified School District’s efforts to provide the safest possible environment in which to learn and work all district employees will be required to be fully vaccinated against COVID-19 by October 15, 2021.

We urge all educators and school staff to get vaccinated to keep themselves and the students in their care safe.

Employee Name: *

Employee ID #:

Site: *

Role/Assignment: *

I understand that if I decline to respond or am not fully vaccinated, I must comply with the following safety protocols while in a facility:

Wear a mask regardless of the level of community transmission;
Provide proof of having received a negative COVID-19 test weekly.

The Centers for Disease Control and Prevention considers an individual fully vaccinated if they are:

2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or
2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine

If you don’t meet these requirements, regardless of your age, you are not fully vaccinated.

If you are not vaccinated due to medical or religious reasons, please check either “I have not been vaccinated” or “I decline to respond.”

My Vaccination Status:

I am fully vaccinated.

I am not yet fully vaccinated.

I have not been vaccinated.

I decline to respond.

Vaccination Card:

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Printed Name:

Date:

Consequence of Failure to Provide Information: Providing vaccine information is voluntary. However, if you fail to provide this information, you will be considered as not fully vaccinated for purposes of implementing safety measures and will be required to test weekly. Failure to provide vaccination verification or weekly testing may result in disciplinary action up to and including termination.

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