DPS COVID Vaccination Attestation Form

  • In accordance with the North Carolina Strong Schools Toolkit, students and staff who are fully vaccinated are not required to quarantine if they have been identified as a close contact. “Fully vaccinated” is defined as having received the final dose of a one- or two-dose vaccine two weeks or longer before the date of possible exposure. Fully vaccinated students and staff may remain at work/school after exposure with this signed attestation form. 

    Please note that you are required to provide accurate information about the exposed individual’s vaccination status in response to the questions below, or alternatively you may decline to provide vaccination status. If you decline to provide information about the individual’s vaccination status, DPS will be required to assume the individual is unvaccinated for purposes of compliance with the Strong Schools Toolkit’s mandate of full vaccination as a condition of not having to quarantine. 

    When verifying an individual’s vaccine status, acceptable documentation includes either (1) original or photocopy of an official CDC vaccination card, (2) documentation on letterhead from a health care provider that the individual is fully vaccinated, or (3) documentation from the state immunization information system. Proof of vaccination can be obtained at https://covid19.ncdhhs.gov/vaccines/after-youve-been-vaccinated/your-vaccine-information. Directions for obtaining proof of vaccination are also included in the attached flyer. 

    Please sign and return this self-attestation, along with proof of vaccination to return to work/school 

    Self-Attestation/Student Attestation

    By signing this form, I attest that I have received the COVID-19 vaccination or my student has received the vaccine more than two weeks from this date and am/is considered fully vaccinated under the guidelines in the North Carolina Strong Schools Tool Kit. 

    Print Name (employee/parent/guardian):________________________________________________________________

    If applicable, print student Name(s):____________________________________________________________________

    Signature of employee/parent/guardian:_________________________________________________________________