COVID-19 Vaccination & Test Result Registration Form

COVID-19 Vaccination Registration Form
Hand and Hand
As per the Government announcement on Monday 11th of October, all our employee need to follow the new requirements. Everyone at the centre will be required to return a negative COVID-19 result by 26 October or before you join the bubble and get fully vaccinated by 1st January. This survey is to help the group to collect the information. All your information would be kept in a confidential file.*
I Understand it. (Please select to continue)

Please select the statement below that accurately describes your vaccination status:*
I am fully vaccinated.I received my second dose of the Pfizer vaccine less than two weeks ago.I received my first dose of Pfizer, and my second appointment is scheduled.I have not yet been vaccinated, but I have already scheduled an appointment to receive my first dose of vaccine.I have not been vaccinated.I decline to answer whether I have been vaccinated.
Please select the date you received/scheduled the FIRST does:
MonthDayYear
Date
Please select the date you received/scheduled the SECOND does:
MonthDayYear
Date
Upload the Photo of Vaccination Here
Cancelof

Please be aware that:
If you are not vaccinated, you will be required to undergo weekly Covid-19 testing until you have received both vaccinations.
You will be required to provide evidence of receiving your first vaccination by 15th November 2021.
You will be required to provide evidence of receiving your second vaccination by 1st January 2022.
If you have any concerns or questions please feel free to talk to your manager.

I understand that I am required to provide accurate information in response to the questions above. I hereby affirm that I have accurately and truthfully answered the questions above. I also understand that if I stated that I am fully vaccinated, my employer may request documentation of my vaccination status (e.g., a copy of my vaccine card or other similar official document confirming vaccination status).*
Yes
Should be Empty:

COVID-19 Vaccination Registration Form