Proof of compliance to COVID-19 Vaccination Policy
Name
*
First Name
Last Name
Email
*
example@example.com. For Staff, Faculty and Students please use your CCNM email account
Phone Number
*
Please enter a valid phone number.
Please select your Vaccination Status
*
Please Select
Fully Vaccinated (2 doses)
Fully Vaccinated (3rd dose)
Medically Exempted
Education Session Completed
First Dose, getting 2nd dose soon
For the purposes of this survey, “fully vaccinated” means having received the full series of a COVID-19 vaccine or combination of COVID-19 vaccines approved by WHO (e.g., two doses of a two-dose vaccine series, or one dose of a single-dose vaccine series); and having received the final dose of the COVID-19 vaccine at least 14 days ago.
Date
-
Month
-
Day
Year
Date
Please select which group you belong to
*
Please Select
Faculty
Staff
Students
Contractors
Volunteers
Continuing Education
Upload your supporting documents here
*
Browse Files
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i.e. Proof of Vaccination, Medical Exemption, or Certificate of Educational Training
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