MBL COVID-19 Vaccination Booster Status and Attestation

Name*

First NameLast Name

Email*

Please use your @mbl.edu email if you have one.

MBL Card Number

The 5 digit number on the front of your MBL ID card (if known).

Date of Birth*

Vaccination and Booster Status

The MBL requires all research and education program participants and employees to be fully vaccinated with the inclusion of a booster shot. Although only one booster shot is required, the MBL strongly recommends that individuals continue to receive vaccine boosters as recommended by the Centers for Disease Control and Prevention.

Are you up to date with your COVID-19 vaccines?*

Which COVID-19 vaccine did you initially receive (not the booster)?*

Vaccine Doses

12

What date did you receive your initial vaccine dose for a single dose vaccine, or your second dose of a two dose vaccine (not the booster)?*

Which COVID-19 vaccine booster did you receive?*

What date did you receive your booster?*

Upload image(s) of proof of vaccination and booster (i.e. vaccine card)*

Vaccination Exemptions

The MBL requires all employees to be up to date with their COVID-19 vaccines. If you do not meet this criteria please contact MBL Human Resources to discuss your qualifying exemption.

Acknowledgement and Attestation Regarding COVID-19

The COVID-19 pandemic has created substantial individual and community health risks. Even with extensive planning and focus on the community’s health and safety, the Marine Biological Laboratory (MBL) cannot eliminate these risks. We can try to reduce risk to the community if each of us commits to fostering a culture of shared responsibility for our individual and collective health and safety. The MBL expects every person who comes to an MBL facility, whether as an employee, faculty member, postdoctoral researcher, student, visitor, or volunteer, (collectively “MBL visitors”) to adopt precautions designed to mitigate the risk of viral transmission. The MBL has outlined these safety precautions on goforward.mbl.edu.

All individuals must acknowledge and attest to the following before entering any of MBL’s offices, laboratories, classrooms, or other MBL facilities:

I intend to confirm that I am up to date with all recommended COVID-19 vaccinations, including any booster dose(s) when eligible by uploading proof of vaccination or by providing proof of an exemption as required on the MBL goforward website. I understand that if I do not meet the MBL’s vaccination requirement then I may need to be tested in accordance with the MBL’s Asymptomatic Testing Program.
I will conduct a Mandatory Daily Health Screening for COVID-19 symptoms every day before arriving on campus (whether off campus or in residence in MBL housing), and I will monitor my health for new symptoms throughout the day. If I am experiencing any symptoms associated with COVID-19, I will immediately inform my supervisor or primary MBL contact and Human Resources, I will get a COVID-19 PCR test, if possible, and I will not enter any MBL facilities (or will remain in my assigned MBL residence) until criteria in the Protocol for Addressing Confirmed or Suspected COVID-19 Exposures are met.
If I have tested positive for COVID-19, I will seek appropriate medical care, if needed. I will contact Human Resources who may initiate campus contact tracing. I will isolate at home or in a designated housing location at the MBL until criteria as laid out in the Protocol for Addressing Confirmed or Suspected COVID-19 Exposures are met.
I will follow the masking requirement should there be any in effect at the MBL. If I am not up to date with all recommended COVID-19 vaccinations, then I will follow the COVID-19 precautions required by the MBL based on my COVID-19 vaccination status.
I will fully cooperate in MBL’s Contact Tracing Program.
While on campus and accessing MBL facilities, I will not give anyone my MBL ID Card to access any MBL facilities and I will not let anyone into an MBL facility.

ONGOING COMMITMENT

By choosing to enter MBL’s campus or any of MBL’s facilities, I am making an ongoing commitment to follow the COVID-19-related guidance and safety precautions communicated by the MBL. I acknowledge this guidance may continue to change as new information becomes available, and that it is my responsibility to stay informed. I understand that the MBL relies on the commitment of every employee to comply with all safety policies and guidelines. I understand that if we, as a community, do not adhere to the MBL and public health authority rules and guidance (both on and off campus), and a COVID-19 outbreak occurs, the MBL may need to end an on-campus experience.

INHERENT RISK

I understand that the MBL continues to take steps to mitigate the risk of infection to members of our community. I recognize that COVID-19 poses a serious public health risk and that the MBL is not able to guarantee a COVID-19-free environment or eliminate the chance of infection and associated health risks. By entering the campus or any MBL facility, I acknowledge my responsibility to contribute to the collective efforts of the MBL community to reduce the risk of COVID-19 transmission, and I understand that these efforts will not eliminate the risk of transmission.

NON-COMPLIANCE

I understand that my failure to follow the requirements set forth in this attestation may endanger myself and/or others and cause further disruption of MBL research and educational activities. I understand that I may be subject to disciplinary action, including but not limited to: (i) a written warning, (ii) suspension of MBL privileges including access rights to MBL facilities and other resources, and (iii) removal from MBL properties or dismissal from participating in MBL activities. If I believe that MBL required safety policies and practices are not being followed by others, I will promptly report such issues through the MBL Human Resources Dept hr@mbl.edu or Environmental Health & Safety safety@mbl.edu.

By clicking the box below, I acknowledge and attest to the conditions as provided*

I Agree

Signature*

Clear

After you press Submit and your response is recorded, a confirmation email will be sent to the address you entered above, usually within a 5-10 minutes. If you do not receive this email please contact hr@mbl.edu.