Clinical Instructor COVID-19 Vaccination Status
Name
*
First Name
Last Name
Email
*
example@example.com
Consent
I agree to provide my vaccination status information.
What is your COVID-10 Vaccination Status?
*
Fully Vaccinated - Primary series of 2 doses
First booster received (total 3 doses received)
Second booster received (total 4 doses received)
Exemption
Not Vaccinated
Date of first dose
/
Month
/
Day
Year
Date
Date of second dose
/
Month
/
Day
Year
Date
Date of third (first booster) dose, if received
/
Month
/
Day
Year
Date
Date of fourth (second booster) dose, if received
/
Month
/
Day
Year
Date
Upload proof of Vaccine doses
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of
What vaccine brand(s) was/were administered?
Upload proof of exemption
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of
Submit
Should be Empty: