Employee Immunization Compliance Form
Employee Name
Employee ID
Department
Position/Job Title
MMR (Measles, Mumps, Rubella)
Compliant
Not Compliant
Exempt
Varicella (Chickenpox)
Compliant
Not Compliant
Exempt
Hepatitis B
Compliant
Not Compliant
Exempt
Tdap (Tetanus, Diphtheria, Pertussis)
Compliant
Not Compliant
Exempt
Influenza
Compliant
Not Compliant
Exempt
COVID-19
Compliant
Not Compliant
Exempt
Notes or Comments