Covid-19 Vaccine Assessment

The Centers for Disease Control and Prevention recommends the Covid-19 vaccine for everyone over 5 years of age. CMS requires Mercer Health to report healthcare workers vaccination status for Covid-19.

Name(Required)

First Last

Date of Birth(Required)

Are you a student or a provider?(Required)

Expected time frame of student in Mercer Health Facility (estimated start and end date):(Required)

Clinical Placement Department(s):(Required)

Name of Instructor:(Required)

Name of School:(Required)

Job Title:(Required)

Specialty:(Required)

Expected time frame of provider in Mercer Health Facility (estimated start and end date):(Required)

Please Complete the section below:

Have you received the Covid-19 vaccination?(Required)

Please upload a copy of your vaccination card with date and manufacturer information.(Required)

Max. file size: 300 MB.

Signature(Required)

CAPTCHA

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