Certificate of Compliance – Town of Vinalhaven

Keep Vinalhaven Healthy

For the safety of the community, the Public Health Team asks that anyone coming to the island from out-of-state who will not be completing a Certificate of Compliance at a rental establishment, complete and submit one with the Town. Those under the age of under the age of 18, or residents traveling to and from Maine, New Hampshire, and Vermont, do not need to complete a Certificate of Compliance.

All questions with an * must be answered in order to submit this form.

Question Title

* I certify that I have not experienced or displayed any of the following COVID-19 symptoms in the last 24 hours:

Fever or chills

Sore throat, cough, shortness of breath, or other respiratory symptoms

Muscle aches, severe fatigue, or chills

Changes in taste or smell

Question Title

* I certify that...

I have not had close contact with anyone over the last 10 days who is confirmed to have COVID-19.

Question Title

* I certify that ONE of the following is true (PLEASE CHECK ONE):

I have received a negative test result for COVID-19 on a specimen taken no later than 72 hours prior to my arrival, consistent with Maine CDC guidance.

I will quarantine for 10 days upon arrival in Maine or for the duration of the stay.

I have completed a 10-day quarantine in Maine prior to my stay.

Question Title

* While in Maine, I agree to do my part to Keep Maine Healthy by following recommended safety measures in order to protect myself and others.

Yes

Question Title

* 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 and 2.

Yes

N/A

Question Title

* Please provide the ages of such persons in your care.

Person 1

Person 2

Person 3

Person 4

Person 5

Person 6

Question Title

* I have read and understand this entire Certificate of Compliance and agree the certifications made above are accurate.

Yes

Question Title

* Please provide the following information:

Date

First Name

Last Name

Vinalhaven Address

Vinalhaven Phone

Permanent Residence Phone

Question Title

* Additional Persons over 18 from the Same Household

First and Last Name

Question Title

* Thank you for doing your part to keep yourself, your family, and your community safe.

For Vinalhaven COVD-19 Community Guidelines and up-to-date information, visit the COVID-19 pages on the Town website. www.townofvinalhaven.org

Please share questions and comments in the box below or reach out to the Emergency Operations Center (EOC) team at VHEOC@townofvinalhaven.org 207-833-2168