COVID-19 ATTESTATION FORM

Employee ID Number:*

If you are not sure what your Employee ID number is, it can be found on your badge (if you have one) and on Greenshades.

Are you fully vaccinated?*

Yes
No

*“Fully vaccinated” means it has been two weeks since a person received the second dose of Pfizer or Moderna or the single dose of Johnson & Johnson. Integrity is one of our core values, and we trust that employees will respect that principle when answering the attestation.

Are you partially vaccinated?*

Yes
No

*“Partially vaccinated” means it has been two weeks since a person received the first dose of Pfizer or Moderna. Integrity is one of our core values, and we trust that employees will respect that principle when answering the attestation.

Have You Submitted Proof of Vaccination?*

Yes
No

If you have not summitted proof of vaccination already please e-mail vax@mirabito.com and attach a picture of your vaccination record or a screenshot of your excelsior pass.
Please also include your Name and Employee ID#

You can also text the word VAX to (833)348-2017 and follow the prompts.

In the past 24 hours, did you experience any of the following?

Fever (100.4 degree fever or higher), or feeling feverish?*

Yes
No

Cough?*

Yes
No

Shortness of breath or difficulty breathing?*

Yes
No

Chills?*

Yes
No

Repeated shaking with chills?*

Yes
No

New sore throat?*

Yes
No

New muscle aches or pains?*

Yes
No

New headache?*

Yes
No

New loss of smell or taste?*

Yes
No

If you answered YES to any of the questions above, what was the most recent date you had a symptom?

Have you had any known exposure to COVID 19?*

Yes
No

Have you tested positive to COVID 19?*

Yes
No

Have you been taken out of work by a medical provider awaiting COVID 19 test results?*

Yes
No

Have you traveled internationally?*

Yes
No

If you answered YES to ANY of the questions above, please provide a contact phone number.

All employees except non-management convenience store employees, must complete this form prior to reporting to work every day of the work week.

In the past 24 hours, did you experience any of the following?