Acknowledgement 

To qualify for a vaccine incentive payment, I am uploading documentation to show that I am fully vaccinated for COVID-19 and/or that I have received a flu vaccination since August 1, 2021.  I understand that to qualify for a COVID-19 vaccine incentive, I will need to upload a copy of my official COVID-19 vaccination card to show that I am fully vaccinated for COVID-19.  Further, to be considered fully vaccinated for COVID-19, my official vaccination card must show that I have received at least one dose of the Janssen (Johnson & Johnson) vaccine or at least two doses of the Pfizer or Moderna COVID-19 vaccine by February 25, 2022. I further understand that to qualify for the flu vaccine incentive, I will need to upload documentation from the organization or medical provider that administered the flu vaccination that includes at least my name and the date and type of flu vaccination, which must have been administered after August 1, 2021. 

I am uploading this vaccination information voluntarily to apply for a vaccine incentive payment, and I understand that I would not be subject to discipline for choosing not to provide information about my vaccination status at this time (though requirements may be subject to change in the future).  I understand that any vaccination information I provide will be treated as confidential medical information and will be kept separate from my personnel file. 

I verify that the documentation I am uploading is accurate, true and correct, and understand that providing documentation that contains false information could result in discipline up to and including termination of my employment.

This acknowledgement language does not negate vaccination and/or disclosure requirements established by certain departments/offices that are outside the CEO's chain of command.