Documents and Forms

Vaccination Requirement Information

Documents and Forms

IF YOU ARE A STATE CONTRACTOR: you should not use the below forms to submit information, but may use them as templates as you develop forms for your own staff and contractors. These are specifically for State Employees at this time. Please contact your contracting agency for further information, and visit our Knowledge Base for further details specific to your situation.

Attestation Forms

Testing Attestation Form (en español)
Attesting to true and accurate representation of recent test results.

Vaccination Attestation Form (en español)
Attesting to the personal vaccination record and that the information included in that document is true.

When you submit the above forms, please also include your vaccination card and/or test results as appropriate. The form alone, or a test result/vaccination card alone is not a complete submission.

Exemption Forms

Temporary Waiver from Weekly COVID-19 Testing on the Basis of Prior COVID-19 Infection
If you are a state employee or other covered worker, you may request a temporary waiver from the weekly SARS-CoV-2 testing for the 90 days after your COVID-19 diagnosis.

To request this waiver, individuals must have their healthcare provider complete the form below and both you and your healthcare provider must attest to the accuracy of the information provided. Once the form is completed, please submit it to WellSpark using the fax and/or email provided within the document.

Please note the below medical and religious exemption forms are only required if your role is one of the few, such as those in health care facilities, that does not allow a test out option without an exemption. Please be in touch with your human resources representative should you require additional clarification.

Medical Exemption for COVID-19 Vaccination
To request a medical exemption to the COVID-19 vaccination requirement, please complete this form and have your physician, physician assistant, or advanced practice registered nurse complete the information. Once the form is completed, please submit it to WellSpark using the fax and/or email provided within the document.

Request for Religious or Spiritual Exemption from Mandatory COVID-19 Vaccination Order
State Hospital Employees may apply for a religious or spiritual exemption from the requirement to obtain the COVID-19 vaccine by using this request form. If you have a sincerely held religious or spiritual belief that you believe prevents you from receiving the COVID-19 vaccine, you must sign and submit the request form. Once the form is completed, please submit it to WellSpark using the fax and/or email provided within the document. All requests and supporting documentation will be reviewed by an agency-designated Human Resources representative. The agency-designated Human Resources representative may contact you for additional information or for clarification.