Facility COVID-19 Vaccination Status Log
UPDATED DECEMBER 2022 - New Column for Booster Dose(s)
Facility COVID-19 Vaccination Status Log documents compliance with CMS-3415-IFC issued and effective November 5, 2021.
Use this status log within your facility to record the name, status, vaccine administration, exemptions granted/denied as well as comments. You may wish to complete a separate form for employees, another form for volunteers, etc.
Surveyors will ask for a list of all staff and their vaccination status. This log will help you comply with that request and the IFC.
Size: 11 x 8 ½
Print: Black ink – 2 sides
Punching: 5-holes top and side
Packaging: 50 per pad