Self-Certification of Vaccination Status Form – For Students

COVID-19, is a highly infectious, life-threatening disease declared by the World Health Organization to be a global pandemic. Although COVID-19’s highly contagious nature means that contact with others or contact with surfaces that have been exposed to the virus, can lead to infection, the current COVID 19 vaccines have proven to be both safe and extremely effective in preventing the transmission of the COVID-19 virus and the minimization of symptoms for those who do contract it. Individuals who may have been infected with COVID-19 may be asymptomatic for a period of time or may never become symptomatic at all. Because of its highly contagious and sometimes “hidden” nature, it is currently very difficult to control the spread of COVID-19 or to determine whether, where, or how a specific individual may have been exposed to the disease. Like most colleges and universities in the state of California, the University of Silicon Valley (USV) will require students to be vaccinated in order to return to campus starting the Fall 2021 term. To return to campus, all vaccinated students must: 1. Complete the Self Certification of Vaccination Form 2. Provide visible proof of vaccination. Once all steps have been completed, your student ID will be activated granting you access to campus. Students who fail to complete these requirements will NOT be permitted on campus.

First & Last Name: (no nicknames)*

First Last

Student ID

Email*

Please select the statement below that accurately describes your vaccination status:*

I am fully vaccinated.
I received my second dose of the Pfizer or Moderna vaccine or my single dose of a Johnson & Johnson vaccine less than two weeks ago.
I received my first dose of Moderna or Pfizer, and my second appointment is scheduled.
I have not yet been vaccinated, but I have already scheduled an appointment to receive my first dose of vaccine.
I have not been vaccinated.
I decline to answer whether I have been vaccinated.

Are you sharing COVID Test Results?

Yes
No

Please upload your test results here*

Max. file size: 50 MB.

Upload the front of your vaccination card

Max. file size: 50 MB.

If you have not done so, please show proof of vaccination to a college administrator or upload a copy here

Signature*

By checking this box I understand that I am required to provide accurate information in response to the question above. I hereby affirm that I have accurately and truthfully answered the question above. I also understand that if I stated that I am fully vaccinated, documentation of my vaccination status (e.g., a copy of my vaccine card or other similar official document confirming vaccination status) will be required.

Name*

First Last

Date*

Self-Certification of Vaccination Status - For Students