HR Vaccination Disclosure Form

HR Vaccination Disclosure Form

Purpose: This form collects employee vaccination information for purposes of workplace health and safety, accommodation assessment, and limited verification. Information provided will be treated as confidential medical information and stored separately from the personnel file in accordance with applicable law. Falsification or omission of material information may result in corrective action up to and including termination.

Personal Information

Employee Name:

Employee ID:    Date of Birth:

Position Information

Reporting Manager:    Start Date (with Company):

Vaccination Status

Select applicable status (check all that apply):
Fully vaccinated (primary series completed)
Partially vaccinated
Booster dose received
Not vaccinated
Prefer not to disclose

Vaccine Manufacturer(s):

Dose 1 Date:    Dose 2 Date (if applicable):    Booster Date (if applicable):

Exemption Request (if applicable)

I request an exemption from the vaccination requirement for the following reason(s):
Medical exemption
Religious belief/observance
Other (describe below)

I will provide supporting documentation: Yes    No

Acknowledgements and Authorizations

By signing this form I certify that the information I have provided is true and complete to the best of my knowledge. I understand that deliberate falsification may result in discipline, up to and including termination. I authorize the Company to verify vaccination information with health care providers, vaccination registries, and previous employers when necessary to confirm the information provided here.

I acknowledge that vaccination status and related medical information will be maintained separately from my general personnel record, that access will be limited to those with a legitimate need to know, and that the Company will use reasonable measures to protect confidentiality in accordance with applicable law.

Consent to Verification: I consent to the Company contacting my health care provider(s), prior employers, or public health authorities for verification purposes.

Employment History (most recent first)

Job Title:    Dates Employed: From to

Job Title:    Dates Employed: From to

Education

Graduation Date:

Professional References (provide three)

Phone:    Email:

Phone:    Email:

Phone:    Email:

Legal Notices

At-Will Employment: Nothing in this form alters the at-will nature of employment. Employment remains at-will and may be terminated by either the employee or the Company at any time, with or without cause or notice, unless otherwise specified in a separate written agreement signed by authorized Company representatives.

Equal Employment Opportunity: The Company prohibits discrimination or harassment on the basis of any protected characteristic. Requests for exemptions or accommodations based on medical conditions or sincerely held religious beliefs will be evaluated in accordance with applicable law and Company policy.

Applicant Certification

I certify that all information provided on this form is true, complete and accurate. I understand that the Company may rely on this information in administering workplace health and safety measures, and that I may be required to provide additional documentation to substantiate any claims made herein. I authorize the Company to obtain and verify records and information necessary to confirm the information contained in this form.

I understand that submission of this form does not automatically constitute an approved exemption or accommodation; any accommodation will be determined following an interactive process and review of supporting documentation.

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