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*
Date Format: MM slash DD slash YYYY
I certify that (please select one):*
- I am a critical worker 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 been in a county in NY, RI, MA, ME, NH, or CT with fewer than 400 active COVID-19 cases per million, as set forth on the Vermont Agency of Commerce and Community Development’s website*, and I did not travel to Vermont by air or bus; OR
- I have traveled to Vermont from another state, and I traveled directly from my home in my personal vehicle, and I have completed a 14-day self-quarantine (or a 7-day self-quarantine followed by a negative test result) in that state; OR
- I have traveled to Vermont from another state, and I will complete a 14-day self-quarantine (or a 7-day self-quarantine followed by 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.
*
- 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.
*
- 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);
- Used a fever reducer (in the past 24 hours, have you used any medicine that reduces fevers?);
- Chills;
- Repeated shaking with chills;
- Muscle pain;
- Headache;
- Sore throat;
- New loss of taste or smell.
- 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:
*
- 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*
Date Format: MM slash DD slash YYYY
Location Signed*
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