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  • Completing this form is a confirmation to follow safety control measures and a voluntary representation of your vaccination status. Inaccurate vaccination status confirmation violates 3M's Code of Conduct, which may lead to disciplinary action up to and including termination. In your vaccination status confirmation you are required to provide truthful and accurate information about your COVID-19 vaccination status. If your vaccination status changes you can submit a new form at any time.

     

    3M will not and cannot retaliate against you regardless of your response. If you think you have been retaliated against based on your completion of this vaccination status confirmation, you should report those actions immediately to 3M Human Resources.

     

    You may decline to respond with your vaccination status. Declining to provide your vaccination status will require you to still abide by all 3M COVID-19 protocols.

     

    You are considered "fully vaccinated" 14 days after completing the second dose of an authorized two-dose COVID-19 vaccine (e.g., Pfizer, Moderna, etc.) or 14 days after receiving a single dose of an authorized one-dose vaccine (e.g., Johnson & Johnson/Janssen, etc.).

  • COVID-19 Vaccination Status and Safety Controls Confirmation

  • By pushing the submit button, I certify and affirm that I am providing accurate and truthful information in this form. I understand that if I stated that I am fully vaccinated, 3M may request documentation of my vaccination status (e.g., view a copy of my COVID-19 vaccination record card or other similar official document confirming my vaccination status). I will also abide by the location specific controls and protocols based on my current vaccination status.

    The information you provide on this form will be used to administer COVID-19 protocol exception program. The information will be kept confidential according to applicable law and 3M policies including the CCPA Worker Notice (PDF, 102 KB) where applicable. 3M may share your vaccination status with your supervisor, other site management, Occupational Medicine, and HR on a need-to-know basis only. 

  • Submit

Thank you!

Thank you for submitting your COVID-19 vaccination status and safety controls confirmation. Your response has been logged. If your vaccination status changes you can submit a new form at any time.

Submitting your confirmation may allow certain COVID-19 protocols to become optional for you. Please follow the prescribed protocol for your location.

Infographic signifying 3M on site COVID-19 protocols. 3M strongly encourages getting vaccinated, if you're feeling sick monitor your health and practice good personal hygiene.

Thank you!

Your response has been submitted successfully. Based on the information you provided, it has not been 14 days or more since receiving your last vaccination dose. Fourteen days after your last dose of vaccine, you will be fully vaccinated. This may allow certain COVID-19 protocols to become optional for you once your fully vaccinated.

Infographic signifying 3M on site COVID-19 protocols. If you're not fully vaccinated, please distance yourself from others, avoid crowded spaces and wear face covering in posted areas.

Thank you!

Your response has been submitted successfully. You have submitted that you are unvaccinated or decline to respond with your vaccination status. You are required to continue to abide by 3M COVID-19 protocols, including but not limited to, physical distancing and space occupancy requirements (e.g., time restrictions, higher performance face coverings, portable HEPA units, etc.).

Contact your supervisor if you have questions.

Infographic signifying 3M on site COVID-19 protocols. If you're not fully vaccinated, please distance yourself from others, avoid crowded spaces and wear face covering in posted areas.

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