COVID 19 Vaccination Information Form

Acceptable Documentation of Completed Vaccination Includes:

• A copy of the Centers for Disease Control (CDC) COVID-19 Vaccination Record Card;
• Documentation of vaccination from a healthcare provider of electronic health record; or
• State immunization information system record.

Acceptable Documentation of Exemption Includes:

• Medical Exemptions – Documentation showing approval, date of approval, and signature of a licensed practitioner recommending exemption
• Religious Exemptions – Official documentation showing approval of religious exemption with date of approval.

For each dose received (including any booster doses), please provide the dose type, brand, date of receipt, and location of receipt.