Scribd
Upload
2K views1 page

Local Government COVID-19 Attestation Form

This attestation form declares that: [1] all individuals listed are eligible to receive the COVID-19 vaccine as part of the priority population of General Santos City; [2] the individuals provided their information voluntarily to be included in the Vaccine Information Management System for reducing COVID-19 risks, in accordance with data privacy laws; and [3] the signatory verified that the information is true and correct to the best of their knowledge.

Uploaded by

consi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
2K views1 page

Local Government COVID-19 Attestation Form

This attestation form declares that: [1] all individuals listed are eligible to receive the COVID-19 vaccine as part of the priority population of General Santos City; [2] the individuals provided their information voluntarily to be included in the Vaccine Information Management System for reducing COVID-19 risks, in accordance with data privacy laws; and [3] the signatory verified that the information is true and correct to the best of their knowledge.

Uploaded by

consi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Attestation Form

ATTESTATION FORM

I, _________________________________________________________________________,
____________________________________________, the duly authorized representative of
______________________________________________ do hereby declare and attest to the
following:

1. That all individuals listed are part of this facility/institution of Local Government Unit
of General Santos City; are among the list of the priority population; and are eligible
to receive the COVID-19 vaccine;

2. That all individuals listed in the Vaccine Information Management System - 


Immunization Registry (VIMS-IR) have provided the information indicated therein
with full knowledge that the processing thereof is necessary for the generation of the
masterlist for vaccination to the VIMS-IR in order to reduce the morbidity and
mortality due to COVID-19, in accordance with the Republic Act No. 10173,
otherwise known as the Data Privacy Act of 2012;

3. That all individuals listed in the VIMS-IR Form and encoded/uploaded to the VIMS-
IR have provided the information indicated therein with expectation that the relevant
government agencies will uphold the rights of the data subjects, implement the
appropriate security measures, and will remain adherent to the general data privacy
principles of transparency, legitimate purpose, and proportionality, in processing their
personal information; and

4. That all matters set forth in this VIMS-IR Form or uploaded to the VIMS-IR have
been made in good faith, duly verified by me and to the best of my knowledge and
belief are true and correct.

Done this ____ day of _______________, 2021 in __________________.

By:

_____________________________________________

You might also like