Employee COVID-19 Immunization Form

Employee COVID-19 Immunization Form
Name*

First NameLast Name
Number*
900XXXXXX
Email*
example@adams.edu
Have you received your full or partial COVID 19 Vaccination or booster?*

YesNo
What type of vaccination or booster did your receive? (select all that apply)

Pfizer-BioNTech First dosePfizer-BioNTech Second doseModerna First doseModerna Second doseJohnson & Johnson/JanssenPfizer-BioNTech BoosterModerna Booster
Date of First/Single Dose

MonthDayYear
Date
Date of Second Dose

MonthDayYear
Date
Date of Booster Dose

MonthDayYear
Date
You have indicated you have not received your COVID-19 Vaccination please indicate below if you are requesting an exemption.

Exemption - MedicalExemption - PersonalExemption - ReligiousExemption - Off Campus (Faculty or Staff who never visit campus)
If you are requesting an exemption please download the appropriate form, complete the form and upload it below.
- Employee Medical Exemption Form
- Employee Non-Medical Exemption Form (Personal or Religious)
Please upload a copy of your Vaccination Card or Exemption request form

Cancelof
Should be Empty: