Staff Vaccination Verification

Staff Vaccination Verification

Last Name*

First Name*

Position*

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School/Division*

Select your School or Division from the drop down list.

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Primary Work Location

Select or enter value

Vaccination Status*

Select

Upload proof of vaccination here:*

Drag and drop files here or

Date of Birth*

Required by Maryland Department of Health and CIAN Diagnostics. This information will not be included in school/division reports.

Home Street Address*

Required by Maryland Department of Health and CIAN Diagnostics. This information will not be included in school/division reports.

City*

State*

Zip Code*

Phone Number

Phone

Acknowledgement*

I understand that Baltimore County Public Schools has issued a vaccination mandate for all staff. Onsite weekly COVID testing will be offered to all staff and required for staff who do not submit proof of their being fully vaccinated against COVID. I understand that CIAN Diagnostics will report the results of my weekly testing to my Supervisor and the Office of Health Services.

Electronic Signature*

Send me a copy of my responses

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