Faculty/Staff COVID-19 Vaccination Verification

Please provide the requested information below if you are fully vaccinated against the COVID-19 virus.

Your Name Your Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Medaille ID
Must be 8 digits. Currently Entered: 0 digits.
Medaille Email
Are you...

Are you... Faculty member Staff member
Your Permanent Address Your Permanent Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cellphone Number Cellphone Number - ### - ### ####
Please upload a photo of your vaccination card

Attach Files
Check the box below if you have lost your COVID-19 vaccination card

Check the box below if you have lost your COVID-19 vaccination card I lost my COVID-19 vaccination card.
Please provide the following information regarding your COVID-19 vaccination: Location(s) you received your dose(s), date of your final dose.