COVID-19 Vaccination Record Updated on: February 5, 2021 Please submit this form within 30 days of your completed vaccination. Name* First Last Email* I am a* Faculty member Staff member Student Which COVID-19 vaccination/booster did you have?* Single dose series Two dose series Booster Date of COVID-19 Vaccination MM slash DD slash YYYY Date of first dose of COVID-19 Vaccination MM slash DD slash YYYY Date of second dose of COVID-19 Vaccination MM slash DD slash YYYY Date of COVID-19 Booster MM slash DD slash YYYY Please upload a copy of your COVID-19 Vaccination Record Card* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.