Human Resources Vaccination Reporting Form

Select your description

Student ID Number

First Name

Last Name

ETBU email address

Phone

Please select the option that best describes your vaccination status

Please select the best description for your status

Vaccine Manufacturer

Date of First Vaccination

Date of Second Vaccination (if applicable)

Date of Third Vaccination (if applicable)

Date of Fourth Vaccination (if applicable)

Please upload your COVID-19 Vaccination Card here

Please upload your COVID-19 Vaccination Exemption Documentation here. If you have questions or concerns regarding providing documentation, please reach out to Tara Bachtel at tbachtel@etbu.edu.
One file only.
75 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.