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COVID-19 Vaccine Self-Certification Form Template

Streamline Your COVID-19 Vaccination Certification Process

Navigating the COVID-19 vaccination process can be overwhelming, especially when ensuring compliance with certification requirements. This COVID-19 Vaccine Self-Certification Form Template helps healthcare providers and organizations efficiently gather necessary vaccination information from patients or clients. With this form, you can simplify data collection, ensure a smoother vaccination process, and reduce administrative workload, all while maintaining accuracy and compliance. Plus, its WCAG-aligned design ensures accessibility for everyone. Explore how this template can streamline your certification process.

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Full name
Date of birth
Email address
Phone number
ZIP or postal code
What is your current COVID-19 vaccination status?
Not vaccinated
Partially vaccinated (1 dose)
Completed primary series
Received at least one booster
Prefer not to say
Which COVID-19 vaccine manufacturers have you received? Select all that apply.
Pfizer-BioNTech
Moderna
Johnson & Johnson (Janssen)
Novavax
AstraZeneca
Not applicable
Prefer not to say
Other
Please Specify:
Date of most recent COVID-19 vaccine dose (if any)
Do you have a CDC or official vaccination record card available?
Yes
No
Please indicate any reasons that apply to your eligibility to receive a COVID-19 vaccine or booster.
Age-based eligibility
Qualifying medical condition
Healthcare worker
Work in a high-risk non-healthcare setting
Live in a high-risk congregate setting
Eligible under current local guidance
Prefer not to say
Other
Please Specify:
Are you currently feeling ill?
Yes
No
Do you have a fever today?
Yes
No
Have you had a severe allergic reaction (for example, anaphylaxis) to any vaccine or injectable medication?
Yes
No
Have you had a severe allergic reaction after a previous COVID-19 vaccine dose?
Yes
No
Have you tested positive for COVID-19 in the past 90 days?
Yes
No
Have you received COVID-19 treatment (for example, antivirals or monoclonal antibodies) in the past 90 days?
Yes
No
I certify that the information provided in this form is true and complete to the best of my knowledge.
Yes
No
Signature (type your full name)
Date of signature
I consent to the use of my information for verifying COVID-19 vaccination eligibility and scheduling.
Yes
No
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Paper art illustration representing a flu shot proof form for FormCreatorAI article.

When to use this form

Use this self-certification when you need a quick, signed record of vaccination status from employees, students, contractors, or volunteers. It is ideal for new-hire onboarding, campus housing check-in, healthcare shift assignments, and event access control. The form creates a time-stamped statement you can store with HR or compliance files and reference during audits. If someone declines vaccination, pair it with a COVID-19 Vaccine declination form to document the decision. Clinics and hospitals can attach it to intake alongside a Patient admission and consent form to keep related authorizations together.

Must Ask COVID-19 Vaccine Self-Certification Questions

  1. What is your current COVID-19 vaccination status?

    This shows whether the person meets your policy and what follow-up is needed. If they are not vaccinated, route them to the COVID-19 Vaccine declination form to record the reason.

  2. Which vaccine product did you receive and on what dates, including any boosters?

    Product and dose dates confirm completion and help you plan next-dose timing. If you schedule another dose, pair it with the COVID-19 Vaccine consent form for efficient intake.

  3. Do you attest that the information provided is true and accurate?

    An attestation discourages false reporting and supports audits. It also clarifies accountability for HR or program administrators.

  4. May we verify your status with your healthcare provider and share it with the designated department for safety compliance?

    Permission to verify and share reduces back-and-forth while respecting privacy boundaries. If your policy requires a separate release, collect a HIPAA Authorization form.

  5. Do you have a medical or religious exemption on file, or are you requesting one?

    This flags the need for accommodations and defines next steps. It helps you plan testing, masking, or assignment changes.

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