Faculty Vaccination Survey Faculty name* Email* By completing this form, you acknowledge that providing the office with your vaccination preference and/or records is strictly voluntary. If applicable, you may choose to indicate that you do not wish to disclose your information.* I understand You also acknowledge that your selection in the following question regarding your vaccination status/preference may be shared with parents and/or students. Your vaccine record, should you wish to share it, will remain confidential.* I understand Please select the statement that applies to you:* I am fully vaccinated I am partially vaccinated and plan to get my second dose I am partially vaccinated and do not plan to get my second dose I am not yet vaccinated but plan to do so I am not vaccinated and do not plan to do so I do not wish to disclose my vaccination status or preference Are you willing to provide the VAM office with a copy of your vaccination record?*Note: any records you voluntarily submit are for office use only and will not be shared. Yes, I will upload a copy with this form No, I do not wish to share my records Upload a copy of your vaccination record here:Max. file size: 2 MB. Δ
