COVID-19 Vaccine Information

Question Title

* 1. First Name:

Question Title

* 2. Last Name:

Question Title

* 3. Email:

Question Title

* 4. Please indicate your University affiliation:

Faculty

Staff

Returning Student

Incoming First-Year/Transfer Student

Graduate Student

Physical Therapy Student

Question Title

* 5. Have you received your COVID-19 Vaccine?

Yes

No

No, but plan to before Aug 23

Question Title

* 6. What vaccine did you recieve?

Johnson & Johnson

Moderna

Pfizer-BioNTech

Question Title

* 7. On what date did you receive your final shot?

Date / Time

Date

Question Title

* 8. Please upload your COVID-19 vaccination record card:

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.