Library Staff Vaccination Assessment Form
Use this form to assess vaccination status and related work-readiness for library staff. Please provide accurate information so the assessment can be reviewed appropriately.
Staff Identification
Full Name
*
First Name
Middle Name
Last Name
Job Title / Role
*
Department / Branch
*
Work Email
example@example.com
Vaccination Status Assessment
Vaccination status
*
Fully vaccinated
Partially vaccinated
Not vaccinated
Prefer not to say
Vaccine type/manufacturer
Please Select
Pfizer-BioNTech
Moderna
Novavax
Johnson & Johnson
AstraZeneca
Other
Number of doses received
Date of most recent dose
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Documentation available
*
Yes
No
Partial
Prefer not to say
Booster and Exemption Information
Booster received
*
Yes
No
Not sure
Date of most recent booster
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for not being vaccinated or not up to date
Medical reason
Personal choice
Religious or philosophical reason
Access or scheduling barrier
Recent illness or recovery
Other
Exemption status
*
Requested
Already on file
Not requested
Brief explanation of exemption request
Work Readiness and Exposure Assessment
Confidence in Current Vaccination Compliance
*
Low Confidence
1
2
3
4
High Confidence
5
1 is Low Confidence, 5 is High Confidence
Symptoms or Recent Exposure Screening
*
Rows
Yes
No
Symptoms present
1
2
Recent close contact
3
4
Positive test
5
6
Currently in isolation
7
8
Current Work Clearance Status
*
Cleared to work on-site
Pending review
Requires follow-up
Acknowledgment and Follow-up
Preferred contact time for follow-up
Hour Minutes
AM
PM
AM/PM Option
Submit Assessment
Should be Empty: