Attestation Form 1

Personal Information

	Employee	Manager
Name:
PRI/HRMIS number for RCMP/ DND service number for military:
Date of birth:
Organization:

I attest that my COVID-19 vaccination status is: (required)

As defined by the Policy on COVID-19 Vaccination for the Core Public Administration Including the Royal Canadian Mounted Police

Fully Vaccinated
Partially Vaccinated (in addition to your attestation, you must also provide your manager with the date of your first vaccination
Unvaccinated
Unvaccinated becuase I am requesting accomodation

I am requesting accomodation

This section is required if you have indicated that you are unvaccinated because you require accommodation.

Due to a medical contraindication
Under a prohibited ground of discrimination under s.3(1) of the Canadian Human Rights Act

Indicate Canadian Human Rights Act ground

This section is required if you have indicated that you are unvaccinated under a prohibited ground of discrimination under s.3(1) of the Canadian Human Rights Act.

Religion
Another prohibited ground under s.3(1) of the Canadian Human Rights Act

By submitting this form, I certify that the statements I have made and the information I have disclosed in this form are true, complete, correct and in accordance with the Values and Ethics Code for the Public Sector. I understand that if my vaccination status changes, I must complete a new vaccination status attestation. I acknowledge that the information I submit in this form is subject to verification and audit and I specifically acknowledge that my manager reserves the right, at the manager's sole discretion, to request proof of vaccination.