Report of COVID-19 Vaccination Status

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In order to be properly prepared, we are asking all students, faculty and staff to submit a “Report of COVID-19 Vaccination Status” form before the start of the school year. This information will inform our decisions regarding protocols for keeping the Merion Mercy community healthy and safe. It is also necessary for performing contact tracing should that be needed.

We are asking everyone to complete this form, regardless of whether or not you have submitted it in the past, to ensure that we have the most up to date information as we start the new school year.

Thank you for your understanding and cooperation.

Marianne Grace
Director of Operations

Email *

First Name *

Last Name *

Please check one of the boxes below: *

Teaching Faculty

Staff

Coach

Other:

Required

Have you been vaccinated for COVID-19? *

Yes

If vaccinated, type of vaccine:

Pfizer (2 shots)

Moderna (2 shots)

Johnson & Johnson (one shot)

Clear selection

If vaccinated when was your first shot?

YYYY

If vaccinated when was your second shot (for Moderna and Pfizer)?

YYYY

Submit

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