COVID-19 Vaccination Status

This form was developed to gather COVID-19 vaccination information from employees to aid our staff in implementing testing, quarantine, and tracing and tracking protocols. The information will be gathered and maintained in the Human Resources Office.

Name Name First Last
Status
Department
Date Date / MM / DD YYYY
COVID Test Results
Vaccination Record
According to the CDC, "people are considered fully vaccinated two weeks after their second dose in a two-dose series, such as the Pfizer or Moderna vaccines, or two weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine."
Date of first vaccination Date of first vaccination / MM / DD YYYY
Date of second vaccination (if applicable) Date of second vaccination (if applicable) / MM / DD YYYY
Date of booster Date of booster / MM / DD YYYY
Photo of vaccination record (Required)

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