Flu Vaccine Self-Reporting Form

Use this form to report your flu vaccine, which will be added to your record in CoVerified and shared with Health Services (students) or the Office of Human Resources (employees).

All University community members must complete this form no later than Friday, January 8, 2021. Failure to complete the form will result in CoVerified restriction.

Are you a:

Are you a: Student Employee (Faculty or Staff)
Name Name First Last
University Email (must list UNH email address)
Did you receive a flu shot this flu season (after Sept. 1, 2020)?

Did you receive a flu shot this flu season (after Sept. 1, 2020)? Yes No, but I plan to No, I will not be receiving a flu shot this year
Where did you obtain your flu shot (name of doctor's office, name of pharmacy, etc.)?
Date of your flu shot (must be the 2020-21 flu vaccination - after August 1, 2020). Please approximate if you don't have the exact date. Date of your flu shot (must be the 2020-21 flu vaccination - after August 1, 2020). Please approximate if you don't have the exact date. / MM / DD YYYY
You indicated you have not yet received a flu shot, but plan to. Do you have an appointment scheduled?

You indicated you have not yet received a flu shot, but plan to. Do you have an appointment scheduled? Yes, on-campus Yes, off-campus No
You indicated you do not plan to receive the flu shot this year. Please let us know why, below:

You indicated you do not plan to receive the flu shot this year. Please let us know why, below: Do not believe the flu shot is effective Do not believe in vaccinations Religious reasons Cannot receive due to medical condition / exemption Other Other