I, the undersigned, wish to provide evidence of my vaccination status to CTEH, and I wish to have my immunization status considered, in the sole discretion of CTEH, during the production. I understand that I will be required to present my vaccination card as requested by CTEH, and my vaccination card may be copied for retention by CTEH. I certify that, to the best of my knowledge, the vaccination card that I have attached here is valid and current, and was created and presented to me in conjunction with my receipt of the COVID-19 vaccine.
I understand that CTEH will take steps to protect my identity and the confidentiality of my information. I also understand that CTEH may disclose my personal information to public health authorities where required.
By checking the box below, you authorize CTEH to document and verify your vaccination status, as needed. You are entitled to a copy of this Consent. Any questions regarding this consent should be directed to your employer or designated representative.