2. Information

   Effective September 17, 2021, pursuant Contra Costa Health Services Order No. HO-COVID19-53, first responders are mandated to obtain weekly testing for COVID-19 or provide documentation of their fully vaccinated status. 

   Instructions for unvaccinated police officers: Complete the form below to record weekly COVID-19 testing results. If you have any questions, please contact Human Resources directly by emailing sbassi@ci.el-cerrito.ca.us or calling (510) 215-4315.

4. First Name*
5. Last Name*
7. Position *
9. Name of Witness*
11. Date and Time of Test*
    Date and Time of Test

    Date and Time of Test
13. Result*
    -- Select One --Negative PositiveInconclusive

15. Employee Attest:

    I attest that I am providing accurate information about my test results. I hereby affirm that I have accurately and truthfully recorded the information above.  By completing and submitting the online version of the Employee COVID-19 Test Results Self-Attest Form, this signifies my signature.  

17. First Name*
18. Last Name*
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field