Employee Vaccination Assessment
Please complete this form to provide your vaccination status and related information for workplace health and safety compliance.
Full Name
*
First Name
Last Name
Employee ID
*
Department
*
Email Address
*
example@example.com
Vaccination Status
*
Fully vaccinated (all recommended doses)
Partially vaccinated (some doses)
Not vaccinated
Prefer not to say
Type of Vaccine Received
Please Select
Pfizer-BioNTech
Moderna
Johnson & Johnson
AstraZeneca
Other
Date of Most Recent Vaccination
-
Month
-
Day
Year
Date
Are you claiming a medical or religious exemption?
*
No
Medical exemption
Religious exemption
If you are claiming an exemption, please provide brief details
Please rate your understanding of the company's vaccination policy
*
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
Do you have any questions or comments regarding the vaccination policy?
Submit Assessment
Should be Empty: