Clay Fitness LLC - Vaccination Status Affirmation

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Name:*

Date:*

Please Select One*

Clay Fitness LLC Employee
Clay Fitness LLC Contractor
Clay Fitness LLC Client

For the purposes of this certification, you are considered “fully vaccinated” * if it has been at least 14 days since you received either a single-dose COVID-1 vaccine (e.g. Johnson & Johnson/Janssen), or the second dose in a two-dose COVID-19 vaccine series (e.g. Pfizer or Moderna). If it has been 6 months or more since your final vaccine, “fully vaccinated” also means you have received a booster vaccine dose.

* Vaccines must be FDA approved; have an emergency use authorization from the FDA; or, for persons fully vaccinated outside the United States, be listed for emergency use by the World Health Organization (WHO).

Please select the statement below that accurately describes your vaccination status:*

I am fully vaccinated (as defined above).
I am not yet fully vaccinated (it has not yet been at least 14 days after my last COVID-19 vaccine dose, or it has been more than 6 months since my last COVID-19 vaccine and I have not been boosted).
I have not yet been vaccinated.

Vaccien Received:*

Pfizer
Moderna
J&J
Other

Approximate date of final dose (month/year):*

Approximate date of most recent booster received (month/year):

I hereby affirm that I have accurately and truthfully completed this form. (type full name and date)*

Vaccination Status Affirmation

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