Vermont Certificate of Compliance

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Confirmation Number*

Date of Arrival*

I certify that (please select one):*

I am traveling for essential purposes as defined by the State of Vermont; OR
I have not left the state of Vermont for any reason except essential travel in the past 14 days; OR
I have traveled to Vermont from another state, and I traveled directly from my home in my personal vehicle only after having first completed a 14-day self-quarantine (or a 7-day self-quarantine and followed by the time required to obtain a negative test result) in that state; OR
I have traveled to Vermont from another state, and I will complete a self-quarantine (up to 14 days or a 7-day self-quarantine followed by the time required to obtain a negative test result) in Vermont at a lodging establishment or residence, and I acknowledge that I must stay in my quarantine location for the duration of the quarantine, including the time required to obtain a negative test result.

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I also certify that, to my knowledge, I have not had close contact within the past 14 days with a person confirmed to have COVID-19.

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I also certify that, I am traveling only with members of my household, am staying in a lodging property with only members of my household, and I will not gather with members outside of my household while in Vermont.

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I also certify that I do not currently, and have not had in the past 24 hours, any of the following symptoms:

• Cough;
• Difficulty breathing;
• Fever (feeling feverish or have a measured temperature at or above 100.4°F/38°C);
• Chills;
• Repeated shaking with chills;
• Muscle or body aches;
• Headache;
• Sore throat;
• New loss of taste or smell;
• Congestion or runny nose;
• Nausea or vomiting, diarrhea.

I also certify that all persons in my care who are under the age of 18 or who are dependent on my care meet the criteria described in items 1–3 above. Please provide a list of the names of all such persons in your care.

Please provide a list of the names of all such persons in your care:

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By way of this form, I have been informed that out-of-state guests are encouraged to register with the Vermont Department of Health’s Sara Alert system* and to provide updates to that system daily.

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I have read and understand this entire Certificate of Compliance and make the above certifications under the pains and penalties of perjury.

*For information related to completing this form, visit: accd.vermont.gov/coc

Name*

First Last

Date Signed*

Location Signed*

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WHAT TO KNOW ABOUT QUARANTINE (per the State of Vermont)

Vermont Certificate of Compliance