COVID-19 Proof of Vaccine Listen Employee Name(Required) First Last Employee NCC Email(Required) Please indicate your COVID-19 vaccination status by checking one of the boxes below:(Required) Fully vaccinated - Employees will be considered fully vaccinated two weeks after receiving the requisite number of doses of a COVID-19 vaccine. Partially vaccinated - Employees will be considered partially vaccinated if they have received only one dose of a two dose vaccine. Not vaccinated Please voluntarily upload your acceptable proof of receiving the COVID-19 VaccinationAcceptable proof of vaccination is: 1. The record of immunization from a health care provider or pharmacy; OR 2. A copy of the COVID-19 Vaccination Record Card; OR 3. A copy of medical records documenting the vaccination; OR 4. A copy of immunization records from a public health, state, or tribal immunization information system; OR 5. A copy of any other official documentation that contains the type of vaccine administered, date(s) of administration, and the name of the health care professional(s) or clinic site(s) administering the vaccine(s). This form will be routed directly to the Human Resources department. Proof of vaccination will be retained in the Human Resources department in each employee’s individual confidential medical personnel folder. Proof of Vaccine Upload(Required)Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.CAPTCHA
