City of Dayton Coronavirus

Vaccination Affidavit

I, ______________________________________________, do hereby agree and certify to the

(Print Name)
following, and my checking each term or condition below indicates my acceptance of

that item: (Please Initial all applicable boxes)

I am aware that effective August 9, 2021, the City of Dayton, Ohio (City)
adopted Personnel Policy 13.04 addressing the City’s Mask, Vaccination,
and Testing Policy.
Vaccination Status
“Fully vaccinated” means two weeks have elapsed since the employee
received the second dose in a two-dose vaccine series like Pfizer or
Moderna, or two weeks after a single-dose vaccine, like Johnson &
Johnson’s Janssen vaccine.

I am fully vaccinated. (You may be required to present proof of vaccination)

I am not fully vaccinated.

I am in the vaccination process; I will be fully vaccinated on .

I decline to provide the City my vaccination status.

You attest that the information you are providing is true and accurate.
Falsification of any information on this affidavit or submitting false
supporting documentation will be grounds for disciplinary action up to,
and including, discharge.

____________________________ ____
Employee Signature Date

____________________ ____
Department

To be completed by Human Resources Staff COVID-19 Weekly Testing Requirement

You are exempt from the City’s weekly COVID-19 testing requirement.

You are required to participate in the City’s weekly COVID-19 testing

requirement until your vaccination status changes.

Processed by: __________________ Date:

Vaccination Affidavit Page 1 of 1 August 9, 2021