CERTIFICATE OF COMPLIANCE - TO VERMONT BE SMART, STAY SAFE EXECUTIVE ORDER 01-20 - Lodging Compliance Form

Oct 6, 2026

Certificate of Compliance for Vermont travel and lodging under Executive Order 01-20. The signer certifies critical-worker status or qualifying recent travel history, including county case thresholds and travel mode restrictions, and acknowledges completion of required 14-day or 7-day quarantine with possible negative test. It also certifies no close COVID-19 contact in the prior 14 days and absence of specified symptoms. Instructions include listing dependent persons under 18, registering out-of-state guests in the Sara Alert system, keeping the form on file for 30 days, and providing signature and printed name with a dated Vermont location.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

Certificate of Compliance

Certification items (1-6)

Signature section (Person 1 and optional Person 2)

Household contact information and instructions to business

| CERTIFICATE OF COMPLIANCE
TO VERMONT BE SMART, STAY SAFE EXECUTIVE ORDER 01-20 | | | --- | --- | | 1. I certify that:
a. I am a critical worker as defined by the State of Vermont; OR
b. I have not left the state of Vermont for any reason except essential travel in the past 14 days; OR
c. I have been in a county in CT; MA; MD; ME; NH; NJ; NY; OH; PA; RI; VA; Washington, D.C.; or WV with fewer than 400 active COVID-19 cases per million, as set forth on the Vermont Agency of Commerce and Community Development’s website*, and I did not travel to Vermont by air or bus; OR
d. I have traveled to Vermont from another state, and I traveled directly from my home in my personal vehicle, and I have completed a 14-day self-quarantine (or a 7-day self-quarantine followed by a negative test result) in that state; OR
e. I have traveled to Vermont from another state, and I will complete a 14-day self-quarantine (or a 7-day self-quarantine followed by a negative test result) in Vermont at a lodging establishment or residence, and I acknowledge that I must stay in my quarantine location for the duration of the quarantine. | | | 2. I also certify that, to my knowledge, I have not had close contact within the past 14 days with a person confirmed to have COVID-19 . | | | 3. I also certify that I do not currently, and have not had in the past 24 hours, any of the following symptoms:
• Cough;
• Difficulty breathing;
• Fever (feeling feverish or have a measured temperature at or above 100.4°F/38°C);
• Used a fever reducer (in the past 24 hours, have you used any medicine that reduces fevers?);
• Chills;
• Repeated shaking with chills;
• Muscle pain;
• Headache;
• Sore throat;
• New loss of taste or smell. | | | 4. 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 1–3 above. Please provide a list of the names of all such persons in your care. | | | 5. By way of this form, I have been informed that out-of-state guests are encouraged to register with the Vermont Department of Health’s Sara Alert system * and to provide updates to that system daily. | | | 6. I have read and understand this entire Certificate of Compliance and make the above certifications under the pains and penalties of perjury.
* For information related to completing this form, [visit:](visit: accd.vermont.gov/coc)[ accd.vermont.gov/coc](visit: accd.vermont.gov/coc)
Dated: in , Vermont. | | | PERSON 1
Signature: | Printed Name: | | PERSON 2 (FROM SAME HOUSEHOLD; OPTIONAL)
Signature: | Printed Name: | HOUSEHOLD CONTACT INFORMATION Address: Phone: Instructions to business: Keep this form on file for 30 days.

FAQs

What does the signer need to certify about travel history before lodging in Vermont?

The signer must confirm critical-worker status or that they have not left Vermont except for essential travel, or that they meet the specified out-of-state county case thresholds and travel restrictions. They must also address required direct travel and completing the applicable self-quarantine period.

What COVID-19 related contacts and symptoms are covered by the certificate?

The certificate confirms there has been no close contact within the past 14 days with a person confirmed to have COVID-19. It also certifies that no listed symptoms were present in the past 24 hours, including cough, difficulty breathing, fever, chills, muscle pain, headache, sore throat, and new loss of taste or smell.

What instructions apply to out-of-state guests and to the business keeping the form?

Out-of-state guests are encouraged to register with the Vermont Department of Health’s Sara Alert system and provide daily updates. The business is instructed to keep the form on file for 30 days.

Oct 6, 2026

Uploaded by River Wang