I agree to the following terms of use:

If submitting Vaccination information:

I declare and attest that the official record I have attached or uploaded is a copy of my personal vaccination record and that the information included in that document is true, to the best of my knowledge. I understand that it is a crime under federal law to use, buy, sell, or transfer a CDC vaccination card knowing that it is fraudulent. A violation of this federal law is punishable by a fine or imprisonment of up to five years. 18 U.S.C. SEC. 1017. Furthermore, I understand that, as provided in Executive Order No. 13G, submitting false written information related to my vaccination status is punishable pursuant to Section 53a-157b of the Connecticut General Statutes by a fine of not more than $2,000 or imprisonment of not more than one year.

If submitting Testing Information:

By making a selection on the testing screen in regards to my results and as required by Executive Order No. 13G, I attest that my selection is a true and accurate representation of my most recent test result, to the best of my knowledge, and that providing false information in response to this question is punishable pursuant to Section 53a-157b of the Connecticut General Statutes by a fine of not more than $2,000 or imprisonment of not more than one year. I understand that I may be contacted and required to provide documentation of my test result for verification.

I understand and agree that the information submitted will be used to determine my compliance with my employer’s COVID-19 testing, vaccination and exemption requirements. I hereby authorize WellSpark Health, Inc., to share the submitted information with Human Resource representatives of my employer.