COVID Vaccine Verification Form

Advocate Aurora Health requires all health care professionals to be fully vaccinated with the COVID-19 vaccine. Please complete this form if you have received your COVID-19 vaccine series outside of our Advocate Aurora COVID Team Member Vaccine Clinic or Employee Health.

Required documentation:

Advocate Aurora requires the following documentation to be completed and returned with this form, no later than 10/15/2021 for current team member

The documentation must include documentation of a completed vaccine series with an FDA-authorized COVID-19 vaccine or, if vaccinated outside of the United States, a COVID-19 vaccine listed for emergency use by the World Health Organization (WHO). A list of the most current COVID-19 vaccines recognized for emergency use by the WHO can be found: https://extranet.who.int/pqweb/vaccines/covid-19-vaccines

Completion of this COVID Vaccine Verification Form

Documentation from the vaccine provider/administrator OR state-based vaccine registry

Forms submitted without proper supporting documentation will not be processed.

What happens if I received a COVID Vaccine series or partial series outside of the United States?

Advocate Aurora will follow the current CDC recommendations for persons vaccinated outside the United States: Interim Clinical Considerations for Use of COVID-19 Vaccines CDC.

Who can I contact if I have a question related to my vaccine verification form or supporting documentation?

Any questions related to this form can be sent to: ad4q9g@r.postjobfree.com.

COVID Vaccine Verification Form

Section 1: Please print legibly. To be completed by team member:

Last Name of Person Who Was Vaccinated:

First Name of Person Who Was Vaccinated:

ID Number/ Payroll Number:

Date of Birth:

Last Four Digits of Social Security #:

Phone Number of Person Who Was Vaccinated:

Facility Where You Work:

Please check one:

Team Member (Employee on Advocate Aurora Payroll Including Employed Physicians)

Non- Employed Credentialed Staff

Volunteer

Contracted Staff

Other (describe position):

Section 2: Please select from the following list of acceptable COVID Vaccine Documentation that is required to be provided with this form. Forms submitted without proper supporting documentation will not be accepted.

Illinois Comprehensive Automated Immunization Registry Exchange (I-CARE)

Wisconsin Immunization Registry (WIR)

Signed electronic record from another employer’s Employee Health Department

LiveWell COVID-19 Vaccine Status (medical record)

Electronic chart record from outside medical provider/health system/retail pharmacy

Photo of the front and back of a COVID-19 Vaccination Record Card* (*only accepted as approved verification documentation through March 31, 2022)

Other (Please describe):

Section 3: Submit Documentation following these steps:

Please submit all completed forms and documentation to:

All team members and employed providers submit verification documentation to ReadySet following these steps.

Wisconsin Non-employed Credentialed Staff: Fax to 414-***-**** or scan and email to ad4q9g@r.postjobfree.com

Illinois non-employed Physicians: Fax to 630-***-**** or scan and email to ad4q9g@r.postjobfree.com

Volunteers: Submit documentation to Volunteer Services

Contracted Staff: ad4q9g@r.postjobfree.com

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