COVID Vaccination Affirmation Report Form 2021-2022 School Year

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Pursuant to 10 NYCRR 2.62 and the NYSDOH Commissioner of Health request regarding weekly testing or vaccination status. On a weekly basis, all staff of (P-12) schools in NYS must provide the following information to the employer/District effective September 2, 2021.

PLEASE NOTE: You are not required to receive the vaccine at this time. Providing this information is not a violation of HIPPA and choosing not to answer will result in you being considered "unvaccinated".

Please respond to report your vaccination status by completing this form.

Last Name: (Unless otherwise ordered, this answer will not be reported to the State) *

First Name: *

What building is your primary work location? *

Community Education Center (50 Main, Lockport)

Conference & Technology Center

LaSalle Prep Learning Center

Niagara Academy

NCTEC

Newfane Learning Center

Niagara Falls Learning Center

N. Tonawanda High School

N. Tonawanda Learning Center

OCTEC

OLC

Roy-Hart Learning Center

Workforce Training Center (6th St., Niagara Falls)

Other

Have you received Vaccine #1? *

Yes

Date of 1st Vaccine - if applicable

YYYY

Have you received Vaccine #2? *

Yes

Date of 2nd Vaccine - if applicable

YYYY

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