I certify that:
a. I am traveling for essential purposes 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 traveled to Vermont from another state, and I traveled directly from my home in my personal

vehicle only after having first completed a 14-day self-quarantine (or a 7-day self-quarantine and

followed by the time required to obtain a negative test result) in that state; OR
d. I have traveled to Vermont from another state, and I will complete a self-quarantine (up to 14 days or a 7-day self-quarantine followed by the time required to obtain 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, including the time required to obtain a negative test result.

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.

I also certify that, I am traveling only with members of my household, am staying in a lodging property with only members of my household, and I will not gather with members outside of my household while in Vermont.

I also certify that I do not currently have, 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);

• Chills;

• Repeated shaking with chills;

• Muscle or body aches;

• Headache;

• Sore throat;

• New loss of taste or smell;

• Congestion or runny nose;

• Nausea or vomiting, diarrhea.

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. I have provided below a list of the names of all such persons in my care: