Construction Worker Vaccination Assessment Form
Use this form to assess vaccination status and follow-up needs for construction workers. The title must remain exactly "Construction Worker Vaccination Assessment Form" throughout the form.
Worker & Job Context
Worker full name
*
First Name
Middle Name
Last Name
Job role / trade
*
Please Select
Carpenter
Electrician
Plumber
Mason
Painter
Ironworker
Laborer
Equipment Operator
Welder
Drywall Installer
Foreman
Other
Employer or crew name
Primary job site / project location
*
Vaccination Assessment
Current vaccination status
*
Up to date
Partially vaccinated
Not vaccinated
Prefer not to say
Vaccine type received, if any
Please Select
Influenza
Tetanus
COVID-19
Hepatitis B
Other
Date of most recent dose or booster
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Any side effects or work-impacting reactions after vaccination
Any known restrictions on receiving future doses
No known restrictions
Medical restriction
Allergy-related restriction
Advised to consult a clinician
Prefer not to say
Confidence in staying current with vaccination guidance
Not confident
1
2
3
4
5
6
7
8
9
Very confident
10
1 is Not confident, 10 is Very confident
Work Readiness & Follow-up
Any temporary work restrictions needed?
*
No restrictions
Modified duties only
Reduced hours
No heavy lifting
No working at heights
Other
Preferred follow-up method for vaccination updates or scheduling reminders
*
Please Select
Email
Phone
Text message
Onsite coordinator
Other
Additional notes or questions from the worker or supervisor
Submit Assessment
Should be Empty: