Attestation of Reciept of Influenza Vaccination
USC Faculty/Staff Health Policy USC requires all faculty and staff working on-site to submit proof of influenza vaccination by November 1, 2021 or upon returning to work on-site through the end of the Spring 2022 semester. Faculty and staff who have received the influenza vaccine and are unable to obtain proof of vaccination may submit this attestation.
Patient Full Name:
Date of Birth:
USC ID# (10 digits):
Date of Vaccination: By signing this declaration, the faculty/staff member verifies they have received required influenza vaccination for the 2020-2021 season, I verify the truth and accuracy of my statements in this Influenza Vaccination Form.
Faculty/Staff Signature:
Date:
FOR USE BY USC STUDENT HEALTH STAFF ONLY Date Received: Date Approved: Date Denied: Reviewer Name (Print): Reviewer Signature:
011121 ATTESFLUV
V: 09/20/21