Vaccination Attestation Form
Employee Name
First Name
Last Name
Job Title
Type a question
COVID-19 Vaccine Brand
Date of the First Shot
-
Month
-
Day
Year
Date
Date of the Second Shot
-
Month
-
Day
Year
Date
Date of the Third Shot (If applicable)
-
Month
-
Day
Year
Date
Today's Date
-
Month
-
Day
Year
Date
Employee Signature
Submit
Should be Empty: