COVID-19 Vaccine Documentation

This form is for submitting proof of COVID vaccination only.

If you need to submit your COVID test results click here.
Covid-19 Vaccination Documentation

Illinois Governor J.B. Pritzker announced an Executive Order on Aug. 26, 2021 that requires all higher education personnel and students be vaccinated for COVID-19. The mandate requires individuals to be fully vaccinated (two weeks out from final shot) by Sept. 19. This form will allow the college to begin securely collecting vaccine documentation from team members and students. By submitting your vaccination documentation you will be exempted from weekly testing. Submission of this form will eliminate a requirement for you to provide testing results to the college weekly. As you receive your first dose, second dose, and any potential boosters in the future, you can return to this form and resubmit.
Name *

First Name Last Name
Role at Lewis & Clark *
Date of Birth *

Month Day Year
Date
Lewis & Clark Email Address *
You will not be able to submit this form without entering a valid lc.edu email address.
Phone Number *
Please enter a valid phone number.
Which COVID-19 vaccination have you received? *
Date of first vaccine *

Month Day Year
Date
Date of second vaccine (if applicable)

Month Day Year
Date
Date of booster (if applicable)

Month Day Year
Date
Attach a scan or photo of your COVID-19 vaccination card. *

Please make sure your photo/scan is clearly legible and free of glare before uploading.
Cancel of
I understand that under federal law (18 U.S. Code § 1017) it is illegal to fraudulently or wrongfully use the seal of a U.S. department or agency to any certificate or documentation with knowledge that it is fraudulent, and that penalty for breaking this law is imprisonment up to five years. I also understand that submitting or falsifying records or documentation to the college is a violation of personnel policy and/or student code of conduct, which could include discipline up to and including termination of employment and/or expulsion. *

By checking this box I certify the documentation I have provided is not fraudulent.
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Covid-19 Vaccination Documentation