COVID-19 Vaccine Verification for Employees Name: _______________________________________________ Date: ______________________________________
1. Have you been vaccinated? Yes
If yes, when was your final date of vaccination? ____________
No
2. If you answered yes to being vaccinated, you must provide proof of your vaccination records. Submit a copy of your vaccine card with this form to Jason Hicks.
I hereby confirm that the information I have provided TID regarding my vaccination status is true and accurate as of the date of this submission.
Employee Signature