Gundersen Health System
COVID-19 Vaccine Status
COVID-19 Vaccine Status
Please Answer Yes or No
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
I certify that I have been fully vaccinated against COVID-19.
Yes
No
Attachments
You are required to upload your COVID-19 Vaccination card/proof of immunization.
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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.
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Gundersen ID Number is Required
Gundersen ID Number
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