Gundersen Health System

COVID-19 Vaccine Status

COVID-19 Vaccine Status

Gundersen Health System (GHS) requires COVID-19 vaccination of all staff regardless of work location. This means that all employee and non-employee personnel, volunteers, residents, fellows, trainees, clinical and non-clinical contracted staff, students, researchers, temporary workers, contractors, and vendors at any work site or remote location, regardless of clinical responsibility or patient contact, are required to comply.

Please complete the below information and upload your COVID-19 Vaccination card/proof of immunization in the Attachments section

Attachments

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Electronic Signature

By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.