COVID-19 Immunization Excused Leave Request

Please complete the following form regarding your COVID-19 vaccination(s) and upload a copy of your immunization record as directed.

Employee ID Number (@ followed by 8 digits) *

Employee First Name *

Employee Last Name *

FIT Email Address *

Phone Number

Date of Vaccine #1 *

Date of Vaccine #2 (if applicable)

Immunization Record Upload *

Please upload a copy of your immunization card for your first (and second dose, if applicable).

Drop your files here

Have you submitted a leave report requesting paid time for absence related to receiving the vaccine? *

*

Send me a copy of my responses

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