Student/Trainee/Resident/Instructor COVID Vaccination

1A. I am a(n) *
Student   Instructor   Trainee   Resident  

1B. School Attending or Residency Program *

1C. Program Name *

2. Today's Date: *

3. First and Last Name *

5. Phone Number *

6. Email Address *

7. Have you received a COVID-19 vaccination? If you answer "no" you may choose to complete the Medical or Religious Exemption form. *
Yes   No  

8. Which vaccine did you receive? *
Moderna   Pfizer   Johnson & Johnson   I have not received the vaccination  

9. Have you received the first and second dose? *
Yes   No   I reieved the Johnson & Johnson vaccination   I have not received the covid vaccination  

10. Did you receive a booster? *
Yes   No   I have not received the covid vaccination  

11. If you received a booster, which vaccine booster did you receive? *
Moderna   Pfizer   Johnson & Johnson   None  

12. Do you plan to file an exemption? *
Yes - Medical Exemption   Yes - Religious Exemption   No  

13. By typing my full name below I affirm that the information I am providing is accurate and up to date as of today's date. *

14. Dates of Vaccination(s) *

15. Please upload proof of COVID-19 vaccination card or exemption form. *


16. Additional Upload if backside of card has dates