Clone of Fully Vaccinated Facility Application

The following form is for businesses, facilities, and events that require all individuals entering their indoor space to provide proof of vaccination. To be eligible and to complete this form, facilities and events must:

(1) be prepared to upload a written policy requiring proof of vaccination for both staff and/or employees and guests/visitors/members.

(2) be able to prove that 100% of the individuals in the indoor space have provided proof of vaccination.

If accepted into the program, the representations on this application are considered a condition of your continued participation in the program.

Facilities and events are not required to request or track proof of vaccination for outdoor spaces; however, they may still choose to implement a policy for their outdoor spaces.

NOTE: Facilities that are subject to face covering requirements under Pitkin County Public Health Order (Second Addendum: 08/13/2021), CDPHE Public Health Order 20-38, CDPHE Public Health Order 20-20, and any other public health order (excluding PCPH Public Health Order - Third Addendum) are not eligible for this exception.

Open Records Notification: I acknowledge that my submission is considered an item of public record and all or part of its contents may be subject to public disclosure upon request to Pitkin County under the Colorado Open Records Act (CORA).

The Facility must affirmatively answer each question. If the Facility is unable to answer a question affirmatively, as provided in the dropdown, then the exception is not available to such Facility.

Name of Organization/Facility/Event/Business Applying *

(e.g. "Smith Wedding 10/1/2021", XYZ Business", or "ABC Event Center"

Address of Facility *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Type of Facility *

(e.g. single event (describe type), gym, office, fitness studio, retail, event venue, etc.).

If your facility or event have more than one physical location for which you are applying, please indicate all spaces below

(e.g. names of event spaces or rooms in a hotel - grand ballroom, rooftop lounge, etc.)

Contact Name *

First Name Last Name

Contact Phone Number *

Area Code Phone Number

Contact Email Address *

Please ensure your email is accurate as you will be emailed a copy of this plan.

If different than Contact, name of person filling out this form

First Name Last Name

The Facility has put in place a mandatory vaccination policy for all employees, patrons, and all other persons that enter the Facility. *

Yes

In order to enter the Facility, the Facility’s mandatory vaccination policy requires that a person be fully vaccinated. “Fully vaccinated” means two weeks have passed since the person’s receipt of one course of a single dose COVID-19 vaccine or two doses of any two-dose COVID-19 vaccine. *

Yes

The Facility’s mandatory vaccination policy requires proof of vaccination upon entry to the Facility. *

Yes

The Facility’s mandatory vaccination policy only accepts, as proof of vaccination, the following: COVID-19 Vaccination Record Card (issued by the Department of Health and Human Services Centers for Disease Control & Prevention or WHO Yellow Card) which includes name of person vaccinated, type of vaccine provided, and date last dose administered); a photo of a Vaccination Record Card as a separate document; a photo of the employee's Vaccination Record Card stored on a phone or electronic device; documentation of COVID-19 vaccination from a health care provider; digital record accessed through the myColorado application. *

Yes

The Facility’s mandatory vaccination policy does not permit entry into the Facility to any person that is not fully vaccinated except as required by law. *

Yes

As part of its mandatory vaccination policy, the Facility has developed a reliable process for requiring and checking proof of vaccination for all employees, staff, guests, customers, and all others entering the facility. *

Yes

The Facility will permit inspections by Pitkin County Public Health for compliance. *

Yes

The Facility will have signs posted as entrances that indicate that proof of full vaccination is required for entry and that masks are optional. (signs will be provided upon approval) *

Yes

Recommendations for how to prevent and reduce COVID-19 transmission at your facility/event:

Increase airflow/ventilation
Increase distancing
Limit Capacity
Clean and disinfect frequently touched surfaces
Provide employees, customers, and visitors what they need to clean their hands
Provides employees with training on what to do if sick
Ask employees, staff, and customers who are ill to stay home
Provide online scheduling
Support people who want to wear masks
Encourage people to stay home when sick

For additional information on strategies to prevent and reduce transmission of COVID-19, please visit the Business Playbook for Fall 2021

The facility has reviewed the above recommendations for how to prevent and reduce COVID-19 transmission at the facility/event. *

Yes

I understand that any untrue statement, in any form, or any failure to adhere to the mandatory vaccination policy requirements as set forth in this form while utilizing a masking exception shall constitute a violation of the Order and may result in legal action against the Facility by Pitkin County Public Health. *

Yes

I understand that Pitkin County Public Health cannot provide legal advice and Pitkin County Public Health advises that each Facility consult an attorney concerning its specific circumstances. *

Yes

I understand that Pitkin County Public Health reserves the right to revoke any exception upon observation of any violation of this agreement related to the Facility’s compliance with mandatory vaccination requirements. *

Yes

If approved as a Fully Vaccinated Facility may we share this information with the public? *

Yes No

Please upload a copy of your written Vaccine Mandate Policy *

Browse Files

Written Vaccine Mandate Policy MUST include policies for vaccination verification of ALL individuals who may enter the indoor space (including but not limited to staff, employees, guests, and vendors).

I certify that each of the above answers are true and correct and that any untruthful answers could result in revocation of a exception and/or additional enforcement action by Pitkin County Public Health. *

I certify

We recommend the Facility Contact(s) sign up for the Pitkin County COVID-19 Response and Recovery weekly newsletter to keep up to date with the latest COVID-19 related information in Pitkin County. If you haven't already, sign up below!

Fully Vaccinated Facility Application

General Information

By checking each box, I, on behalf of the Facility, certify that the following are true and correct: