COVID-19 Vaccination Reporting

COVID-19 Vaccination Reporting

Please use this form to report and record the your receipt of the COVID-19 vaccination. Information you report will be utilized in making decisions regarding your return to Prescott College Campus Facilities.
Name *

First Name Last Name
Email *
user.name@prescott.edu
I am a: *

Student Faculty Staff
Department
Campus where you work
Campus where you attend class
Vaccination Information
If you received a vaccination with a single dose, please record that single date below. If you received a vaccination containing two doses, please record both dates.
Vaccination Date *

Month Day Year
Date
Vaccination Date

Month Day Year
Date
Please upload an image of your vaccination card *

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Cancel of
Additional Notes
By signing in the box below, I hereby acknowledge that of the above information is true and accurate to my knowledge. I understand that any false reporting could result in dismissal of employment or enrollment in academic programs.
Signature

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