Employee COVID-19 Vaccine Status Form

Remember, we are not asking for anyone to clarify or explain why they have, or have not, received a vaccination. We also do not need to know where you received your vaccination.

Name*

First Name

Last Name

Campus ID Number*

This form is limited to one submission per ID number.

Vaccination Status
Please submit your answer below.

Please select the option below that best describes your situation.*

I am fully vaccinated against COVID-19. (Received all doses, at least two weeks ago) I am fully vaccinated against COVID-19 AND have received a booster shot. I am currently in the process of getting my COVID-19 vaccine. I am planning on starting the vaccine process soon. I am not planning on getting vaccinated. I am still undecided.