ATTACHMENT M COVID Vaccination Attestation Form-Sample~14.pdf
PDF 93 KB Posted
- Attached to
- Pool Lane Lines & Reels
- Solicitation number
- S-P00400-00003660
- Issued by
- Multnomah County, Oregon
About this file
This is a COVID-19 Vaccination Attestation Form issued by Beaverton School District (BSD) in Beaverton, Oregon, applicable to contractors, suppliers, and service providers working on BSD projects at school facilities. The form requires all personnel engaged to provide goods or services at BSD schools or school-based programs to be fully vaccinated against COVID-19 or possess documented medical or religious exemptions. The attestation must be completed and signed by an authorized contractor representative prior to commencing work, with no specific project deadline or contract term mentioned in the document itself.
The contractor assumes responsibility for obtaining and maintaining vaccination compliance documentation from all employees, associates, subcontractors, and agents for a minimum of two years following project completion. The contractor must provide proof of compliance to the District upon request and agrees to indemnify and defend BSD against any violations or civil penalties resulting from non-compliance with Oregon Administrative Rule 333-019-1030. Additionally, the contractor waives the right to pursue legal action against BSD should any of their personnel contract COVID-19 while providing services to the District. The form requires signature and date completion by both the contractor and BSD representatives to establish agreement with these terms and conditions.
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| File | Type | Posted |
|---|---|---|
| Lane Lines and Reel.pdf |
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Text version
PURCHASING DEPARTMENT
16550 SW Merlo Road, Beaverton, OR 97003-5152 Phone: 503-356-4379 contracts@beaverton.k12.or.us Larry Pelatt – Purchasing Manager
COVID VACCINATION ATTESTATION FOR BEAVERTON SCHOOL DISTRICT (BSD)
CONTRACTORS, SUPPLIERS, AND/OR SERVICE PROVIDERS.
BSD PROJECT NAME____________________ BSD CONTRACT NUMBER______________
In accordance with OAR 333-019-1030, all persons engaged to provide goods and/or services at a BSD school or school-based program which takes place at or in school facilities, must be fully vaccinated against COVID- 19 or have a documented medical or religious exemption. Contractors, subcontractors, and any associated personnel coming to the site are required to be fully vaccinated if they will have direct or indirect contact with students in the course of performing their work. Unvaccinated persons with documented medical or religious exemptions may still be refused access to school sites if the anticipated work would/could put them in direct or indirect contact with students or staff.
Contractor_________________________________________________ by (Authorized Representative) ___________________________________ attests that all of their employees, associates, subcontractors or agents are in compliance with this rule.
Contractor agrees that it is their obligation to obtain documentation of compliance with this rule from each of its employees, associates, agents, or subcontractors.
Contractor further agrees that it will maintain records of such documentation, including vaccination verification and documentation of medical or religious exemptions, for at least two years from the completion of the project.
Contractor further agrees to furnish proof of compliance with this rule to the District at their request and in their sole discretion.
Contractor agrees to indemnify, defend, and hold harmless the District from any violations or civil penalties assessed as a result of Contractor failing to comply with this rule.
Contractor also agrees that Contractor will not pursue, nor will any of their employees, associates, agents, or subcontractors pursue any action against Beaverton School District in the event any of their employees, associates, agents, or subcontractors contracts COVID as a result of the provision of goods or services to Beaverton School District.
Agreed to this __________ Day of _____________ 20__
(Contractor) ________________________ Beaverton School District
By:_______________________________ By:_________________________________
Title:_______________________________ Title:_______________________________
Date:_______________________________ Date:_______________________________ mailto:contracts@beaverton.k12.or.us smithel Text Box
SAMPLE
File details come from the government source that posted it. Updated .