COVID-19 Vaccine/Immunity Disclosure Form


 
 

 

 










Please note, if COVID-19 vaccine records are not submitted, Valard may request proof of your vaccine records at a later date.



If you were diagnosed with COVID-19 more than once, please list any additional dates below

Affirmation

Yes, I certify that the information provided on this form is correct, complete and truthful. I understand that providing false information could negatively impact Valard’s operations and the safety of other Valard employees, their families, and the safety of communities we work in.
No. By clicking “No” this form will be cancelled, and no information will be submitted to Valard. To be clear, by clicking “NO”, Valard will not receive ANY information on this form, the form will be cleared / erased of all entered dataand the form will be completely reset with ZERO data saved.

  In lieu of a signature, I certify that the information entered is correct