COVID-19 Vaccination Documentation
In order to be eligible for “paid administrative leave” for COVID-related reasons under Illinois Public Act 102-0694, a team member (part-time or full-time) must be fully-vaccinated. The definition of “fully-vaccinated” under the Illinois law follows the definition as it is adopted and set by the Illinois Departmentof Public Health (IDPH). Currently, the IDPH considers a person to be “fully-vaccinated” after completing the two-dose series vaccine for Pfizer/Moderna OR the one-dose vaccine for Johnson & Johnson. Provided you have already completed this form and uploaded applicable records to demonstrate your vaccination status to fulfill either of these CDC-approved vaccines, the College has vaccination documentation to verify your eligibility for paid administrative leave for COVID-related reasons. If you wish to do so, you may add additional booster shot information into this form at any time so that the College will have this information proactively should the IDPH revise the definition of “fully-vaccinated” at any time in the future. All vaccination-related fields below are optional, so if you have already added previous vaccination dates (first, second, booster, etc.), you do not need to enter them again. However, each time you add a new vaccine date (first, second, booster, etc.), you must also upload a new attachment.
Name
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First Name
Last Name
Role at Lewis & Clark
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Please Select
Faculty
Staff
Date of Birth
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Month
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Day
Year
Date
Email Address (Lewis & Clark email address is preferred, but not required)
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Phone Number
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Please enter a valid phone number.
Which COVID-19 vaccine did you most recently receive?
Please Select
Johnson & Johnson
Moderna
Pfizer
Date of first vaccine
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Month
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Day
Year
Date
Date of second vaccine
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Month
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Day
Year
Date
Date of most recent booster
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Month
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Day
Year
Date
Attach a scan or photo of your COVID-19 vaccination card.
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Please make sure your photo/scan is clearly legible and free of glare before uploading.
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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.
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By checking this box I certify the documentation I have provided is not fraudulent.
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