eForm - City of Chicago Employee Vaccination Portal

City of Chicago Employee Vaccination Portal

Welcome to the City of Chicago COVID-19 Vaccination Portal. You can use this portal to report your compliance with the City of Chicago COVID-19 Vaccination Policy by either providing your vaccination information or by indicating that you have requested and received an exemption due to either medical necessity or a sincerely held religious belief.

In accordance with the requirements of the Americans with Disabilities Act, the information related to vaccination status and/or medical exemptions, collected through this Portal, will be treated as a confidential medical record and will be retained by the Department of Human Resources in a separate confidential file. Such information will only be shared in accordance with the Americans with Disabilities Act.

Full Legal Name *

Department *

Are you an employee or a volunteer? *

Employee

Volunteer/Non-Employee

Last 4 digits of SSN

Employee ID Your City of Chicago employee number is located on your paystub

Are you vaccinated? *

Yes

Vaccination Manufacturer

Date of First Dose

Date of Second Dose (if applicable)

Proof of Vaccination

Choose File

Type of files: .pdf, .jpeg, .jpg, .gif, .png, .heic, .heif

Have you been granted a medical or religious exemption from the mandatory COVID-19 Vaccination Policy by the City of Chicago's Department of Human Resources?

Yes

Are you opting to be tested?

Yes

I certify that the information I have provided is true and accurate. I also understand that providing any false or misleading information will result in disciplinary action up to and including termination of my employment with the City of Chicago. *

Signature*

Please type the Full Name:

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CHICAGO

City of Chicago Employee Vaccination Portal