COVID-19 Vaccination Self-Certification Form and Verification Process

The below message was sent to SJSU students by the SJSU Student Wellness Center on July 9, 2021.

Dear students, 

In accordance with the pending CSU policy, make sure you are fully vaccinated against COVID-19 before the start of the semester. The COVID-19 vaccine is safe, effective, and the best way you can protect yourself and others. 

Next Steps

  1. Report your vaccination status using the COVID-19 Vaccine Self-Certification form. You will be asked to certify your current vaccination status and indicate if you qualify for a religious or medical exemption. Students requesting a religious exemption can upload their supporting documentation as an attachment on the COVID-19 Vaccine Self-Certification form. Prior to submitting a religious exemption form, please convert the PDF into a .BMP, .JPG, .JPEG, .GIF, or .PNG type attachment. All other attachment types will not be accepted.
  2. Submit verification on the Student Health Center Patient Portal. You will need to submit proof of your COVID-19 vaccination record and/or request for a medical exemption. Proof can include a scanned/photo copy of your vaccine card or a record containing all of the following: full name, date of birth, manufacturer/brand of vaccine, vaccine lot number, administration date and site. Please ensure all information is visible and legible in English to prevent delays in verification.

Students must complete both of these steps by August 6, 2021 to meet full vaccination requirements. For students who need to get vaccinated, the Santa Clara County Mobile Vaccine Clinic is hosting COVID-19 vaccine clinics on July 14 and August 4 for students, staff, and faculty at the Student Wellness Center. The Pfizer (2-dose) and Johnson & Johnson (1-dose) vaccine will be available at these clinics. Registration is encouraged but walk-ins are welcome. Additional vaccine sites in California can be found on For international students who are currently outside of the United States, SJSU will accept all World Health Organization (WHO) Emergency Use listed vaccines and other vaccines that have been approved by your country, regardless of their WHO classification. 

For the latest vaccination updates, SJSU has launched the Vaccination page on the Health Advisories website. For submission instructions and exemption forms, please visit the COVID-19 Vaccine Requirements website. Thank you for helping us ensure a safe return to campus life.

We’re here for you!

Student Wellness Center