Office Location (Required) Philadelphia NY - Manhattan NY - Long Island Menlo Park Boca Raton Maryland London Paris Ireland Home Office Vaccination Status (Required) Type of Vaccination Administered (Required) The Name of The Health Care Professional(s), or Clinic Site(s) Administering the Vaccine(s) (Required) Please Upload Acceptable Proof of Vaccination Status (Required)
1. The record of immunization from a health care provider or pharmacy;
2. A copy of the COVID-19 Vaccination Record Card;
3. A copy of medical records documenting the vaccination;
4. A copy of immunization records from a public health, state, or tribal immunization information system; or
5. A copy of any other official documentation that contains the type of vaccine administered, date(s) of administration, and the name of the health care professional(s) or clinic site(s) administering the vaccine(s). Proof of vaccination generally should include the employee’s name, the type of vaccine administered, the date(s) of administration, and the name of the health care professional(s) or clinic site(s) that administered the vaccine. In some cases, state immunization records may not include one or more of these data fields, such as clinic site; in those circumstances the Company will still accept the state immunization record as acceptable proof of vaccination.
I Plan to Get Vaccinated (Required) Type of Anticipated Vaccination (Required) Please Choose Do you want to submit a COVID-19 antibody test result? (Required) Antibody Test Verification Upload (Required)
Unless I can provide a positive COVID-19 antibody test, I understand that by not being vaccinated or not disclosing my vaccination status, I will be required to wear a mask in the workplace at all times.
I declare (or certify, verify, or state) that this statement about my vaccination status is true and accurate. I understand that knowingly providing false information regarding my vaccination status on this form may subject me to criminal penalties.