COVID Vaccination Tracking Form
Congratulations on becoming fully vaccinated! Please use the information found on your COVID-19 Vaccination Record Card provided to you at the time of your vaccination to complete the form below. This information will be retained by Human Resources.

As a fully vaccinated employee, you are now eligible to request your COVID PTO benefit.

Thank you for doing your part in protecting your health and the health and wellbeing of your community.
Sign in to Google to save your progress. Learn more
Last Name *
First Name *
Middle Initial
Year of Birth (YYYY) *
Cell Phone (123-123-1234) *
Division Location - City *
Division Location - State *
Job Title *
Vaccine Manufacturer *
Date of your 1st dose? *
MM
/
DD
/
YYYY
1st Dose Lot Number *
Date of your 2nd dose? (Not required for Johnson & Johnson vaccine)
MM
/
DD
/
YYYY
2nd Dose Lot Number (Not required for Johnson & Johnson vaccine)
The information I have provided on this form is accurate and I understand that I may be required to provide proof of vaccination upon request. *
Required
Would you like a Casella "Got the Shot" ball cap? *
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