Student Booster COVID-19 Vaccine Status

Student COVID-19 Vaccine Booster Status

For the health and safety of our community, declaration of vaccination status (including booster) 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 NameLast 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 with Booster—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 AND I have received a booster shot.Fully Vaccinated without Booster—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 BUT I have NOT received a booster shot because I am not yet eligible due to the date of my last vaccine shot.Partially Vaccinated—I have received one or two shots of the Pfizer/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.Not Vaccinated—I have a medical exemption.Not Vaccinated—I have a religious exemption.I have received a vaccine other than Pfizer, Moderna, or Johnson & Johnson.
Boosters are available six months after completing the primary Pfizer/Moderna vaccination series and two months after completing the primary Johnson & Johnson vaccination. Based on this information, I'll be eligible for a booster on this date:

MonthDayYear
Date
Upload Image of Vaccine Card or Religious/Medical Waiver

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Student COVID-19 Vaccine Booster Status