Visitor Vaccination Verification Submission

First Name *

name must match vaccine card

Last Name *

name must match vaccine card

Email address *

enter a valid email address

Contact Phone Number *

please include 10 - digit number

Reason for visit *

please select an option from the drop down

Sponsoring Department *

please enter the name of the department

Name of sponsoring individual *

please enter the name of the individual sponsoring the visit

Email of sponsoring individual *

please enter the email of the individual sponsoring the visit

ID and Vaccination Card Upload *

Attachments:

Max file size=2GB

please upload the images of a valid government issued ID and the English version of your vaccination card

Vaccination Type *

please select the vaccine type obtained

Date of first dose *

please enter the date of the first dose administered

Date of second dose *

Please enter the date of the second dose administered. If you received a single dose enter the same date twice.

Date of third dose (booster)

please enter the date of the third dose

Vaccine Type

please select the vaccine type obtained

Date of fourth dose (booster)

please enter the date of the fourth dose

Vaccine Type

please select the vaccine type obtained

By checking this box, I certify that I have submitted an accurate and authentic government issued ID and a valid vaccination card.

* Acknowledgement

Check-in with security is required at all campus buildings. Proof of vaccination does not guarantee campus access.

Email Receipt