COVID-19 ATTESTATION FORM

All salaried employees, Metrocenter employees, and hourly Convenience Store Managers of Mirabito must complete this form prior to reporting to work the first day of the work week.


  • 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.
    *“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. If you are NOT fully vaccinated, you must wear a mask. Integrity is one of our core values, and we trust that employees will respect that principle when answering the attestation.
  • In the past week, did you experience any of the following?

  • MM slash DD slash YYYY