Proof of COVID-19 Vaccination

Student Information

Your Name*

Prefix (optional)

First Name

Middle Name (optional)

Last Name

Email Address*

Student ID Number*

What is your home NVU campus?*

Johnson Lyndon NVU Online PCMH (Mental Health Counseling, M.S. sites)

Other:

Did you report your vaccination status to NVU in Fall 2021?*

Yes No

Are you fully vaccinated?*

Yes No

Which initial vaccine did you receive?*

Johnson & Johnson (1 shot) Moderna (2 shots) Pfizer (2 shots)

Other:

Date of first vaccination (or the one shot J&J)*

Date of second vaccination*

Full vaccination is required by the Vermont State Colleges System residential colleges.

Submit a photo of the front your vaccination card.*

No File Chosen

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Submit a photo of the back of your vaccination card.*

No File Chosen

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By my signature, I certify that the information I've submitted in this form is truthful and accurate. *

Use your mouse or finger to draw your signature above