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* First Last WORK LOCATION POSITION DATE FORM WAS COMPLETED MM slash DD slash YYYY 1. Have you been vaccinated? Yes No If no, please jump to number 3. If yes, see belowWhich vaccine did you receive? BioNTech / Pfizer 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 No 2. 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?3. At this time, do you intend to get vaccinated against COVID-19? Yes No Undecided CAPTCHA
