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Vaccine Self Disclosure Form

"*" indicates required fields

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*
MM slash DD slash YYYY
1. Have you been vaccinated?
If no, please jump to number 3. If yes, see below
Which vaccine did you receive?
At this time, have you received ALL doses of your COVID-19 vaccine?
If you received the BioNTech/Pfizer or Moderna / NIAID vaccines, what is the date that you have, or will have, received your final immunization?
3. At this time, do you intend to get vaccinated against COVID-19?
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