COVID-19 Vaccination Self-Report (SUNY Poly Employees)

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Database for self-reporting of SUNY Poly community COVID-19 vaccinations. This database may be used by Human Resources for reporting, scheduling, testing, and similar purposes. Only authorized individuals will have access to this information.

PLEASE NOTE: reporting vaccination information is encouraged but is not required for all employees.

First Name *

Last Name *

Email *

Contact # (preferably cell) *

Campus *

Albany

Utica

Albany + Utica

Office / Department / College *

First Vaccine Manufacturer (e.g. Moderna, Pfizer, J&J, etc...) *

First Vaccine Date *

YYYY

First Vaccine Location *

Second Vaccine Scheduled Date (if known - should be on card)

YYYY

Second Vaccination Date (completed)

YYYY

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