Facility COVID-19 Vaccination Status Log - DIGITAL FORM
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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.
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*This digital form is delivered as a form-fillable PDF and includes 1-year of updates. To receive your electronic file and updates you must complete and return a content license agreement and provide an end-user email address and contact name for file delivery (please allow 2-3 business days for order fulfillment). After 1- year, your update subscription will automatically renew.
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*This digital form is delivered as a form-fillable PDF and includes 1-year of updates. To receive your electronic file and updates you must complete and return a content license agreement and provide an end-user email address and contact name for file delivery (please allow 2-3 business days for order fulfillment). After 1- year, your update subscription will automatically renew.