CMH Employee Number:
First Name:
Last Name:
Department/Facility:
Date Vaccinated:
Have you had any of these symptoms where you got the shot (injection site)?
Have you experienced any of these symptoms today?
Any other symptoms or health conditions you want to report?
How would you rate your symptoms today?
Did any of the symptoms or health conditions you reported today cause you to: Select all that apply
Do you want Employee Health to call you back?
Best number to call:
Thank you for your reporting any symptoms you've had after receiving the COVID Vaccine.
