Seven Hills Employee COVID-19 Vaccination Status Form

Pursuant to a federal mandate, Seven Hills Foundation & Affiliates must survey all employees regarding their vaccination status.

Please complete this survey as soon as possible. If you have any trouble completing the survey or submitting your COVID-19 vaccination card please see your supervisor for assistance.

For purposes of this form, you are considered “fully vaccinated” two weeks after completing the second dose of a two-dose COVID-19 vaccine (e.g., Pfizer or Moderna) or two weeks after receiving a single dose of a one-dose vaccine (e.g., Johnson & Johnson/Janssen).

Question Title

* 1. Please select your vaccination status.

I am fully vaccinated and have provided Seven Hills with a copy of my vaccination card.

I have received my first dose of Pfizer or Moderna and have my second dose scheduled.

I am fully vaccinated and will upload a copy of my card below.

I have received a single dose of the Johnson & Johnson/Janssen vaccine.

I am not vaccinated, but plan to do so.

I am not vaccinated and would like to request a medical or religious exemption.

I am not vaccinated, and I do not plan to get vaccinated.