COVID Vaccination Verification Questionnaire
By law, schools are required to follow the Washington State Department of Health K-12 COVID-19 requirements: Schools are required to track vaccinations for staff, volunteers, and students.

STAFF:
-  Please submit one questionnaire for yourself and proof of vaccination.  **

** IMPORTANT:
Please show or email your proof of vaccination to the office when you submit your vaccination questionnaire. Your proof of vaccination will be deleted/shredded once verification has been confirmed.  Your proof of vaccination will NOT be kept on file.

Acceptable types of verification include:                                                                    
- Vaccine card or photo of vaccine card                                                                        
- Documentation from a health care provider                                                                  
- State immunization information system record.

* VACCINATION:
You are considered fully vaccinated:
• Two weeks after you have received the second dose in a two-dose series (PfizerBioNTech or Moderna)
OR
• Two weeks after you have received a single-dose vaccine (Johnson and Johnson/Janssen)                                            

Thanks so much!

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Who is completing this form? *
LAST NAME of Staff/Volunteer/Student/Visitor: *
FIRST NAME of Staff/Volunteer/Student/Visitor: *
FULL NAME of person completing this questionnaire: *
Location: *
Type of Vaccination: *
Date of FIRST DOSE: *
MM
/
DD
/
YYYY
Date of SECOND DOSE (if applicable):
MM
/
DD
/
YYYY
Date of MOST RECENT booster?  (If applicable)
MM
/
DD
/
YYYY
STATE where received vaccination: *
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