Home Health Aide Vaccination Assessment Form
Assess vaccination status, history, documentation, and follow-up needs for a home health aide. Use the same title exactly throughout the form.
Applicant and Role Information
Applicant Full Name
*
First Name
Middle Name
Last Name
Job Role or Position
*
Home Health Aide
Certified Nursing Assistant
Personal Care Assistant
Licensed Practical Nurse
Registered Nurse
Other
Department or Service Area
Preferred Contact Email or Phone
*
Vaccination Status and History
Current vaccination status
*
Fully vaccinated
Partially vaccinated
Not vaccinated
Unsure
Vaccine history
Most recent vaccination date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Documentation, Exemptions, and Follow-up
Vaccination documentation attached?
*
Yes
No
Exemption or deferral status
*
Please Select
None
Medical exemption
Religious exemption
Temporary deferral
Pending review
Other
Reason or notes
Final assessment status
*
Cleared
Needs review
Requires follow-up
Submit Assessment
Should be Empty: