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 > Covid

Coronavirus Vaccination Form

Moravia Health is managing the COVID-19 pandemic and vaccinations because it is both critical for the health of our community and safe operations. However, employees and contractors may request exemptions from the requirement for medical causes or religious beliefs.

All employees must provide verification of their status by filling out the form below and uploading proof of vaccination or exemption.

    Name *



    Email *

    Phone *



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    Section I: Self-Certification of COVID-19 Vaccination Status (Required)

     I certify that I have received an approved vaccine and that my COVID-19 vaccination status is current. I understand that I may be expected to provide supporting documentation to this effect upon request. I further understand that for purposes of this certification, I am only 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) and that I should not check this box and certify myself until I am fully vaccinated. I certify that I qualify for a medical exemption and have not received a COVID-19 vaccine, nor do I plan to. I understand that I may be expected to provide supporting documentation to this effect upon request. I certify that I qualify for a religious exemption and have not received a COVID-19 vaccine, nor do I plan to. I understand that I may be expected to provide supporting documentation to this effect upon request.



    Section II: Self-Attestation of Accuracy of Information Provided (Required)


     I hereby certify that the statements contained herein are true and correct to the best of my knowledge and belief. I understand that if I knowingly make any false statement herein, I am subject to such penalties as may be prescribed by statute or ordinance.

    Please upload a picture or document showing the proof of vaccination (5-MB limit on file upload).



    Please upload documentation of the religious exemption (5-MB limit on file upload).



    Please upload documentation of the medical exemption (5-MB limit on file upload).





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