COVID-19 Attestation Form

Due to the risks associated with COVID-19, LBFE must take extra precautions to protect our older adults, volunteers, and staff. We ask that all community members who plan to participate in in-person visits or gatherings screen themselves for symptoms and review the risk factors noted below prior to any contact.

LBFE will allow in-person visits between vaccinated volunteers and older adults. An Attestation form must be completed and sent to the LBFE office (emailed or mailed). See attached.

LBFE encourages visits to be outside. Walks and sitting in parks are highly suggested. If participants are visiting indoors, try to keep a window open. All participants must wear a face covering. No food or beverage is permitted. We are asking all participants to follow safety precautions by doing the symptom self-check prior to meeting, wearing masks, and maintaining at least 6 feet social distance during visits. Please verify with LBFE staff before any in-person meeting that all parties are cleared to visit. Office phone number is 415-771-7957.

As of this time, LBFE will not be hosting social gatherings until local and state guidance allows.

Symptom Self-Check Protocol for Older Adults & Volunteers

What is the COVID-19 Symptom Self-Check protocol?

The symptom self-check is required for both older adults and volunteers prior to meeting in-person at the home or at an LBFE in-person gathering. This is to ensure the safety of LBFE older adults, volunteers, and staff members.

Please review the symptoms below. If you have one or more of these symptoms, please let LBFE staff know and cancel or reschedule your visit or event. The LBFE office number is 415-771-7957.

Do you have any of these symptoms that are not caused by another condition?

  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

Frequently Asked Questions (FAQs):

What if I choose not to be vaccinated?

While LBFE does encourage all participants to be vaccinated, some may choose not to be vaccinated.

LBFE requires all volunteers who would like to meet face-to-face with an older adult to be vaccinated and to sign an attestation form that will be held on file with LBFE. If a volunteer is not vaccinated there are several remote volunteer opportunities available.

LBFE older adults do not have to be vaccinated in order to meet in-person, but each participant must wear a mask and follow all safety protocols. LBFE requires that all older adults sign an attestation form that will be held on file with LBFE.

The volunteer will be informed of the older adult’s vaccination status in advance and will be given the option to be reassigned to another older adult if they do not feel comfortable visiting.

We will require all LBFE participants to sign an attestation form regarding their vaccination status for record keeping purposes only. For those older adults who are not vaccinated, we do ask that participants sign an attestation that they are well aware of the risks of meeting in-person during the pandemic and will follow safety precautions by doing symptom self-check prior to meeting, wearing masks, and maintaining at least 6 feet social distance.

For indoor meetings, LBFE participants will make an effort to keep windows or doors open for ventilation if feasible or meet outside whenever possible.

What risk factors should I check before meeting anyone in-person from a different household?

  • Within the past 14 days, having been in close contact (6 feet or close for a total of 15 minutes in a 24-hour period) with a person who is known to have laboratory-confirmed COVID-19.
  • Received orders from a health care provider or federal, state, or local authorities to self quarantine because of close contact with someone who has laboratory-confirmed COVID-19.
  • Currently waiting on the results of COVID-19 diagnostic test due to symptoms, a confirmed close contact, or having been advised to be tested by a healthcare provider or public health official.

Why does LBFE need to have protocols for in-person interactions?

LBFE continues to be committed to safety and well-being of our older adults, volunteers, and staff. Given that older adults have an increased risk of severe illness, LBFE believes it is important that extra precautions are taken beyond CDC recommendations.

If I had “close contact” with someone who has tested positive for COVID-19, can I still participate in LBFE activities?

Under current CDC guidelines, close contact is defined as having been 6 feet or closer for a total of 15 minutes in a 24-hour period to a person with laboratory-confirmed COVID-19. If you believe you have been in close contact with someone with laboratory-confirmed COVID-19, to ensure your safety and the health and safety of others, we ask that you do not participate in any LBFE in person activities for 14 days from exposure.

Where will my vaccinated information be kept?

LBFE does not share any personal information related to older adults or volunteers. Only LBFE staff will keep track of who has been vaccinated and the information will be stored in a secure database. LBFE is keeping track of those vaccinated in order to facilitate future in-person gatherings and ensure safety as outlined by the CDC and the San Francisco Department of Public Health.

What will LBFE do with my signed attestation form?

Attestation forms will be scanned and stored in a secure cloud-based drive. Original forms will be shredded.

Any questions or concerns, please contact Cathy Michalec at (415) 771-7957 or