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Human Resources Vaccination Reporting Form
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Select your description
- Select -
Faculty
Staff
Student
Student ID Number
Name
First Name
Last Name
ETBU email address
Phone
Please select the option that best describes your vaccination status
- Select -
I am fully vaccinated.
I am partially vaccinated.
Please select the best description for your status
- Select -
I need to submit my vaccination information for the first time.
I previously submitted my vaccination record to ETBU Human Resources and do not need to update or resubmit.
I previously submitted my vaccination record to ETBU Human resources, but I would like to update with additional information.
Vaccine Manufacturer
- Select -
Moderna
Pfizer-BioNTech
Johnson & Johnson
Date of First Vaccination
Date of Second Vaccination (if applicable)
Date of Third Vaccination (if applicable)
Date of Fourth Vaccination (if applicable)
Please upload your COVID-19 Vaccination Card here
Please upload your COVID-19 Vaccination Exemption Documentation here. If you have questions or concerns regarding providing documentation, please reach out to Tara Bachtel at
tbachtel@etbu.edu
.
One file only.
75 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
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