This form is to be used for current & active university employees and VCU new hires.

VCU Health System employees do not need to fill out this form.

Dually employed employees must report vaccine documentation or submit an exemption request to both the University and VCU Health System

Please complete this form in its entirety. If you have filled out this form previously, and wish to fill it out again, it must be completed in its entirety.

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First Name Last Name


This is usually the part of your VCU email before


V Number

Please include the V and all zeros.

Example: V00123456

You can find your V number here:

Phone Number


This form must be completed in its entirety prior to filling out exemption information.
The attached medical exemption form should be downloaded and completed by yourself and your Medical Provider.

Please submit this form and a copy of the related medical record to
Late submissions and/or incomplete submissions may affect the approval process.
I understand that while my exemption request is under review, and if approved, I will be required to complete daily health checks, participate in asymptomatic surveillance testing, and adhere to all mitigating health and safety protocols, including wearing masks while on campus.

Anticipated date of first vaccine:

(or only shot, if J&J)

Anticipated date of second vaccine:
I understand that until I am fully vaccinated I am required to test for COVID-19 and submit results on a weekly basis until my vaccine series is complete and reported. I will also be required to complete my daily health check and comply with all other public health measures while on campus.Initials:


COVID-19 can have serious, life-threatening complications, and there is no way to know how COVID-19 will affect you. If you contract COVID-19, you can spread the disease to friends, family, and others around you.

Millions of people in the United States have received COVID-19 vaccines since they were authorized for emergency use by the FDA. These vaccines have undergone and will continue to undergo the most intensive safety monitoring in U.S. history, including both established and new safety monitoring systems and practices.

Based on what we know about vaccines for other diseases and early data from clinical trials, experts believe that getting a COVID-19 vaccine also helps keep you from getting seriously ill, even if you do contract COVID-19.

Getting vaccinated may also protect people around you, particularly people at increased risk for severe illness from COVID-19.


Thank you for uploading your COVID19 CDC Vaccination Card. Employee Health may reach out to you, if they have any questions about the submitted documentation.

If you have any issues regarding uploading your documentation, please contact the IT Help Desk at or (804) 828-2227.

Should vaccine become available to VCU, you will be contacted  with instructions for signing up for a COVID19 Vaccine to be administered at VCU. 

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