Student COVID-19 Vaccine Status
For the health and safety of our community, declaration of vaccination status is required. Be sure that the information you'll give is accurate and complete. This online form is HIPAA compliant and information you provide will remain confidential.
Name
First Name
Last Name
Email
example@example.com
ID Number
You may find your ID number by logging into myCIA and visiting Profile and Settings.
Vaccine Status
Fully Vaccinated—It has been at least two weeks since I have received both shots of the Pfizer/Moderna vaccines or a single shot of the Johnson & Johnson vaccine.
Partially Vaccinated—I have received one shot of the Pfixer/Moderna vaccines or It has been at less than two weeks since I have received both shots of the Pfizer/Moderna vaccines or a single shot of the Johnson & Johnson vaccine.
I have received a vaccine other than Pfizer, Moderna, or Johnson & Johnson.
Not Vaccinated—I have a medical exemption.
Not Vaccinated—I have a religious exemption.
Upload Image of Front of Vaccine Card or Religious/Medical Waiver
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