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)
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Employee First Name
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Employee Last Name
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FIT Email Address
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Phone Number
Date of Vaccine #1
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Date of Vaccine #2 (if applicable)
Immunization Record Upload
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Please upload a copy of your immunization card for your first (and second dose, if applicable).
Drop your files here
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Have you submitted a leave report requesting paid time for absence related to receiving the vaccine?
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Send me a copy of my responses
Submit
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