COVID Protocol Communication |Using Paper Forms
Using paper forms to submit your documentation
If you must use paper forms to submit your vaccine verification or negative test result
documentation, here’s how you can access the forms:
1. Use the forms attached at the end of this document
2. Download and print the forms from the Hub
○ Both forms are posted on the COVID Compliance Guide on the Hub
(hub.boston.gov/covidcompliance) under the section titled Printable
Resources and Forms
3. Visit your Departmental HR rep in-person to obtain a copy of the form you need
Filling out the paper forms
If you are submitting a vaccine verification form:
● FULL NAME:
● BIRTH DATE:
● DEPARTMENT:
● EMPLOYEE/SPONSOR ID:
● EMAIL:
● VACCINE MANUFACTURER:
● DATE OF 1st DOSE:
● DATE OF 2nd DOSE:
● SIGNATURE:
● Attach a copy (not the original document)
of your vaccine card or other COVID-19
vaccination documentation
If you are submitting a negative test result
verification form:
● FULL NAME
● BIRTH DATE
● EMPLOYEE/SPONSOR ID
● DEPARTMENT
● EMAIL
● DATE OF NEGATIVE TEST
● SIGNATURE
● Attach a copy (not the original document) of
your negative screening test result
COVID Protocol Communication |Using Paper Forms
Submitting your Paper Forms
You will bring your printed form and a copy of your verification documentation (not the
original document) to your Department's HR office.
Do not email this form. Because communications via email over the internet are not secure,
there is a possibility that information you include in an email can be intercepted and read by
parties other than the person to whom it is addressed.
Stay tuned for more information about the paper process. Your Department will be in
touch to provide further details.
For further instructions, FAQs, and additional information
regarding this policy or process, please see the Covid
Compliance Guide on the Hub.
● The guide is linked in this banner which will appear at the very top of any page you
visit on the Hub, or you can log in and enter the URL
hub.boston.gov/covidcompliance
COVID VACCINATION
VERIFICATION FORM
Confidential Medical Record
● Submit this paper form only if you are unable to upload your documentation through the COVID
compliance portal on Access Boston (https://access.boston.gov)
● Please print clearly and legibly.
● A photocopy of your vaccination record or other approved documentation must be attached to this
completed form.
● Your signature is required to verify this information and attached documentation.
● Please submit this completed form, with attachment, to your Department Human Resources personnel
or to Central OHR, in printed form. Do not email this form. Because communications via email over
the internet are not secure, there is a possibility that information you include in an email can be
intercepted and read by parties other than the person to whom it is addressed.
FULL NAME:
BIRTH DATE:
DEPARTMENT:
EMPLOYEE/SPONSOR ID:
EMAIL:
VACCINE MANUFACTURER:
DATE OF 1st DOSE:
DATE OF 2nd DOSE:
SIGNATURE:
By signing above, I affirm that the information I have provided is accurate and
complete to the best of my knowledge and belief, and that any misrepresentation of
this information will provide grounds for employment discipline, up to and
including termination.
CITY OF BOSTON | Office of Human Resources | 1 City Hall Square | Room 612 | Boston, MA
NEGATIVE COVID TEST
VERIFICATION FORM
Confidential Medical Record
● Submit this paper form only if you are unable to upload your documentation through the COVID
compliance portal on Access Boston (https://access.boston.gov).
● Please print clearly and legibly.
● A photocopy of your negative screening test result must be attached to this completed form.
● Your signature is required to verify this information and attached documentation.
● Please submit this completed form, with attachment, to your Department Human Resources personnel
or to Central OHR, in printed form. Do not email this form. Because communications via email over
the internet are not secure, there is a possibility that information you include in an email can be
intercepted and read by parties other than the person to whom it is addressed.
FULL NAME:
BIRTH DATE:
EMPLOYEE/SPONSOR ID:
DEPARTMENT:
EMAIL:
DATE OF NEGATIVE TEST:
SIGNATURE:
By signing above, I affirm that the information I have provided is accurate and
complete to the best of my knowledge and belief, and that any
misrepresentation of this information will provide grounds for employment
discipline, up to and including termination.
CITY OF BOSTON | Office of Human Resources | 1 City Hall Square | Room 612 | Boston, MA
