COVID-19 Vaccination - Employee Disclosure

COVID-19 - Employee Vaccination Disclosure Form This form asks for employees to report that they have received the COVID-19 Vaccine. This is a HIPAA compliant request supported by the Department of Labor. As we return employees to the workplace we will be scheduling weekly testing for un-vaccinated employees. The data received through the form will be used for the purposes of assessing our workforce uptake of the vaccine and decision making with respect to the use of other safety measures in the future. If you have any questions about the collection or use of the information, please contact: Director of Human Resources, Denise Starr at starrd@detroitmi.gov.

Department

Division

Employee Last Name

Employee First Name

Employee ID Number

Please upload a copy of your COVID-19 Vaccination Record

Your privacy is extremely important to us. Be assured that this record will be securely maintained within Human Resource records.

Drop your files here

First Shot

If you are unable to upload a copy of your vaccination record, provide dates of first and second shot, along with vaccination location below.

mm/dd/yyyy

Second Shot

If your second shot date is in the future, please put in your scheduled shot date.

1st Booster or Third Shot date

mm/dd/yyyy

2nd Booster Date

mm/dd/yyyy

Vaccination Location

Where were your doses administered? (e.g. CVS, TCF, Ford Field, etc.)

Comment, Questions, Concerns

WARNING: Please do not provide any medical information (such as existing medical conditions) as part of the proof.

Send me a copy of my responses

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