ATC Employee Vaccination Incentive Verification

Employee Vaccination Incentive Verification

Name(Required)

First Last

Enter employee ID number.(Required)

I certify that I am fully vaccinated for COVID-19. Fully vaccinated is defined as having received: One dose of the Johnson & Johnson's Janssen vaccine, OR two dose series of the Pfizer or Moderna vaccines.(Required)

Yes

Enter completion date of full COVID-19 vaccination.(Required)

I understand that falsification of vaccination information submitted may result in disciplinary action, up to and including termination.(Required)

I understand the consequences of falsifying information provided in this form.

I understand the incentive will be added to my paycheck and is subject to taxes.(Required)

I understand the information provided regarding incentive payment processing and taxation.

I understand the incentive payout date is based on the date I submit my Employee Vaccination Verification Incentive form. I have read the Incentive Payout Timeline provided.(Required)

I understand the information provided regarding the incentive payout timeline.

Submission deadline date: January 31, 2022 / Incentive payout date: February 28, 2022

I understand my response to this form will be accessed only by authorized individuals to process the incentive payout. I also understand this information will be maintained and stored securely to produce for audit verification purposes.(Required)

I understand both statements above regarding access and storing of this form response.

I certify that I understand and have answered all questions above truthfully.(Required)

I agree to the statement above.

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ATC Employee Vaccination Incentive Verification

Employee Vaccination Incentive Verification

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