Vaccination Confirmation

This information will only be used internally by Human Resources. Data on the total number vaccinated will be shared with administration, but your individual submission will be held in strict confidence.

Complete this form only when you have received your first vaccination for the COVID-19 virus.

Status (*)
Faculty / Staff
Cadet
Grad / Evening Grad Student
Campus Partner / Non-Citadel Employee (ie. Sodexo, Budd Group, ROTC, etc.)

Invalid Input

Name (*)

Invalid Input

Department (*)

Invalid Input

Contact Phone (*)

Invalid Input

Contact Email (*)

Invalid Input

Medical Provider for Vaccine (MUSC, Roper, Doctor's Office, etc.) (*)

Invalid Input

Date of First Vaccination (*)

Invalid Input

Expected / Completed Date of Second Vaccination (*)

Invalid Input

Please attach a copy of your vaccination card. You may be required to show proof of your vaccination should vaccination become mandatory in the future. (*)

Invalid Input

Confirmation of Vaccination Form