COVID-19 Proof of Vaccination Form

Today's Date*

Select Campus*

Colorado
Utah
Montana

Under Montana Law, RVU MCOM employees are not required to disclose their vaccination status, however an employee may choose to report their status voluntarily. Montana law prohibits discrimination based on vaccination status or possession of an immunity passport. Employees who choose not to disclose their vaccination status are also protected from discrimination.

Your Name*

First Last

Email:

Are you an:*

RVU Employee
Contractor - Standardized Patient
Contractor/Other

Optional vaccine status disclosure:

I would rather not disclose my vaccination status.

Students must submit their Proof of Vaccination to SentryMD by clicking here: Visit SentryMD

Students wishing an exemption for medical or religious reasons, must complete the exemption form found at the bottom of the page by clicking here: Visit SentryMD Vaccine Exemption Request

What company do you represent?*

Address*
Street Address City State ZIP Code

Office contact phone number*

Which vaccine have you received?*

Moderna

Pfizer

Johnson & Johnson

Date of your Johnson & Johnson vaccination*
MM slash DD slash YYYY

Date of your 1st dose*
MM slash DD slash YYYY

Date of your 2nd dose*
MM slash DD slash YYYY

Please upload a copy of your vaccination card*
Accepted file types: jpg, jpeg, png, pdf, gif, Max. file size: 10 MB.

Have you had a booster shot?*

Yes

No

Which booster have you received?*

Moderna

Pfizer

Johnson & Johnson

Date of booster:*
MM slash DD slash YYYY

Acknowledgement*
I agree to the following:
By signing my name below, I attest that I have answered all the questions above truthfully. If I have uploaded a proof of vaccination record, I further attest that this is a legitimately obtained document. Deliberately providing false information on this attestation will initiate an investigation and may result in disciplinary action.

Signature:*