Declaration Attesting to COVID-19 Vaccination Record

On September 17, 2021, the Connecticut Department of Public Health (DPH) issued Implementation Guidance for Executive Order 13G: Vaccination Mandate for Individuals Working for State Facilities, State Hospitals, Public and Non-Public PreK-12 Schools, and Child Care Facilities (“DPH Guidance”).  The DPH Guidance sets forth the form and manner in which individuals subject to Order 13G must prove and authenticate their vaccination status.

Employees that are fully vaccinated and submitted their COVID-19 vaccine card, must complete the attached Declaration Attesting to the Authenticity of an Individuals Covid-19 Vaccination Record in compliance with Executive Order No. 13G.  Please read, complete, sign, date and return to by October 12, 2021.

These regulations are issued to ensure compliance by the Killingly Public Schools (the “District”) with all applicable laws, regulations, and guidance, including, but not limited to, Order 13G and the DPH Guidance.



First page of the PDF file: DeclarationAttestingtotheAuthenticityofanIndividualFillable003