Page 604 - Safety Memo

COVID-19 Vaccination Compliance Certification

In accordance with the Los Angeles Unified School District policy, all vendors who
visit a District campus and/or provide in-person services to students must be fully
vaccinated against COVID-19 by no later than October 15, 2021.

With respect to the Contract, Agreement or Memorandum of Understanding (enter number, if
available____________________) between the Los Angeles Unified School District (“District”) and
________________________________________________________________________ (“VENDOR”),

for provision of______________________________________________________ Services,

PLEASE CHECK BOX AND SIGN BELOW:

REQUIREMENTS SATISFIED

The VENDOR hereby certifies to the District’s governing board that all of its employees*
who may come onto a District Site or otherwise come into contact with District students and
staff have been fully vaccinated against COVID-19.

*“Employee” is to be interpreted broadly to include any individual performing services on your
behalf including, but not limited to, hired staff, subcontractors, volunteers, agents, representatives.

By signing below, under penalty of perjury, I certify that the information contained on this
certification form is accurate. I understand that it is the VENDOR’S sole responsibility to
maintain, update, and provide the District with a current “COVID-19 Vaccination Compliance
Certification,” throughout the duration of VENDOR provided services.

By:
Authorized VENDOR signature
Printed Name: __________________________________
Title: __________________________________ Date: ___________________________

VENDOR Contact Email: _______________________________
VENDOR Contact Phone Number: __________________

Please return completed form to your District sponsor. Your District sponsor is the school or office
that initiated issuance of a contract to your organization or through which you provide, or your
company provides, services to the District.

August 31, 2021