Mayo Clinic Employee
COVID-19 Vaccination Eligibility Verification
version
Name
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LanId
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Employee Id
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Other data
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Please enter or verify the information below.
Full Legal Name
Alternate or Previous Name
Date of Birth
Sex
Female
Male
Nonbinary
Work Location Region
Mayo Clinic Rochester
Mayo Clinic Florida
Mayo Clinic Arizona
MCHS- SEMN
MCHS- SWMN
MCHS- SWWI
MCHS- NWWI
This is the region where the vaccine will be administered.
Mayo Clinic Number
I understand that I am eligible to receive the COVID-19 vaccine based on my job role. I may decide to accept vaccination now or later. This acknowledgement will allow me to schedule vaccination if I choose to do so. I understand that the vaccination information will be shared with Mayo Clinic's Employee and Occupational Health Services Department.
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Program Data Administration
Use this form to download the consent records as a spreadsheet (CSV) to your computer.
Filter by Work Location
All locations
Mayo Clinic Rochester
Mayo Clinic Florida
Mayo Clinic Arizona
MCHS- SEMN
MCHS- SWMN
MCHS- SWWI
MCHS- NWWI
Filter by LAN ID
Filter by MRN
usually a 7 digit number
Filter by Name
search for any part of the name
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