Please enable JavaScript in your browser to complete this form.VOLUNTARY SELF-DISCLOSURE COVID-19 VACCINE SURVEY To prepare for a safe return to our respective offices, and in accordance with the most recent CDC and EEOC guidance, we are asking each employee to voluntarily disclose whether they have received the COVID-19 vaccine, plan to, or are undecided, as restrictions for those who have been fully vaccinated continue to lessen. Please answer each question below to the best of your ability.Name *FirstLastWORK LOCATIONPOSITIONDATE FORM WAS COMPLETED1. Have you been vaccinated?Yes NoIf no, please jump to number 3. If yes, see belowWhich vaccine did you receive?BioNTech / Pfizer (Requires 2 Doses, 21 Days Apart)Moderna / NIAID (Requires 2 Doses, 28 Days Apart)Johnson & Johnson / Janssen(Requires 1 Dose)At this time, have you received ALL doses of your COVID-19 vaccine? Yes No2. What is the date that you received your first immunization?If you received the BioNTech/Pfizer or Moderna / NIAID vaccines, what is the date that you have, or will have, received your final immunization?Single Line Text3. At this time, do you intend to get vaccinated against COVID-19?Yes NoUndecidedSubmit
