Employee COVID-19 Vaccination Status Form

PLEASE COMPLETE THE FORM TO DISCLOSE YOUR CURRENT VACCINATION STATUS. All City of Portland employees are required to be fully vaccinated against COVID-19. Employees may request an exception on the basis of a medical condition or sincerely-held religious belief. Acceptable proof of vaccination includes documentation provided by a tribal, federal, state or local government, or a health care provider, that includes an individual’s name, date of birth, type of COVID-19 vaccination given, date or dates given, depending on whether it is a one-dose or two-dose vaccine, and the name and location of the health care provider or site where the vaccine was administered. Documentation may include but is not limited to a COVID-19 vaccination record card, a copy or digital picture of the vaccination record card, or a print-out from the Oregon Health Authority’s immunization registry. HIPAA Statement The City of Portland is a hybrid entity under HIPAA (Health Insurance Portability and Accountability Act 1996). This designation requires the City to collect a limited data set of protected health information to meet City, State and Federal mandates. To protect the privacy of personal health information under HIPAA, the City of Portland will only use this collected information for tracking compliance with the COVID-19 vaccination mandate; securely retain this information in compliance with HIPAA safeguard requirements; only allow access to this information by authorized City users that have “need to know” responsibilities; train and monitor authorized users who have access to your protected health information (PHI); not disclose this information without your prior consent, unless mandated by State or Federal health authorities; notify you of unauthorized disclosure should that occur; and annually assess City HIPAA safeguards, training, and how to continuously improve the City's HIPAA compliance program.

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Your PERNR can be found here https://www.portlandoregon.gov/apps/employeevalidate/myid.cfm or by looking at a recent pay statement.


Please select your vaccination status*
Type of Vaccination Received

I hereby attest and affirm that the attached document is a true and accurate copy of a valid, authentic COVID-19 vaccination card, certification, or other documentation ("Vaccine Certification"), completed by the healthcare provider who administered a COVID-19 vaccination to me. I further attest and affirm that I have in fact received the COVID-19 vaccination on the date(s) provided on the Vaccine Certification. I acknowledge that any falsification, whether in whole or in part, of a Vaccine Certification is grounds for discipline, up to and including termination.

I hereby attest and affirm that my answer is true to the best of my knowledge.

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