St. David's HealthCare Flu Vaccine Verification and Attestation Form.xlsx

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5	Instructor and Student Flu Verification/Attestation Form
6	Instructions
8	Please complete one form per organization and send to the central contact Nichole Bustos (nichole.bustos@hcahealthcare.com)
9	This document is verification/attestation that the following listed instructor(s)/student(s) have completed the requirements set forth by St. David's HealthCare
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12	Attestation Statement: On behalf of my organization, I acknowledge and attest to St. David's HealthCare that the individuals identified below have been vaccinated with the most recently available seasonal influenza vaccine.
13	Name of Organization: Austin Community College		Email: kbrophym@austincc.edu
14	Contact: Keri Brophy-Martinez		Date: 1/10/2025
15	Student/Instructor Information Please separate by facility, then list alphabetically by last name
16	St. David's Facility (SDGH, RRMC, NAMC, SDSH, HHOA, SDMC,SAMC)	Full Name (Last, First, Middle)	Date of Birth	Semester & Year
17	NAMC	De Los Reyes, Abigail	10/2/1999	Spring/2025
18	SAMC	Rojas, Angel	9/5/2003	Spring/2025
19	HHOA	Al Isawi, Abeer	7/11/2024	Spring/2025
20	SDGH	Ortmann, Caitlain	2/4/1983	Spring/2025
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