Completing the U-M Self-Report Vaccination Form

Environment

U-M Self-Report Vaccination Form

Issue

To complete the form, you will need to give U-M permission to have the information, identify your affiliation to the university, and provide your vaccine dates, vaccine type, and proof of vaccination.

The self-reported vaccination form can be found on Wolverine Access >> COVID19 >> Report COVID19 Vaccination Completed: https://wolverineaccess.umich.edu/collection/all/covid-19 

Resolution

Please read the information at the top of the survey carefully. To complete the form, you will need to answer the following questions: 

1. Carefully read the consent form.  Select “I do not consent” to not share info. Select “I do consent” to agree to share information.

2. Have you received all required doses for your COVID-19 vaccine? (2 doses are required for the Moderna and Pfizer-BioNTech vaccines, 1 dose is required for Janssen [Johnson & Johnson] vaccine.) 

3. Are you a student yes/no

   1. Enrolled in at least one course

4. In what country did you receive your COVID-19 vaccine? 

5. Which type of vaccine did you receive for dose 1? 

6. When did you receive dose 1? 

7. What is the Lot Number for dose 1 (from your COVID-19 Vaccination Record Card)? 

8. Which type of COVID-19 vaccine did you receive for dose 2? 

9. When did you receive dose 2? 

10. What is the Lot Number for dose 2 (from your COVID-19 Vaccination Record Card)? 

11. Attach an image of your proof of vaccination. If you have any questions or any issues uploading the file, please contact the COVID Call Center 734-936-7000.

12. Submit.

Your vaccination information has been recorded and will be reviewed in up to 7 business days. The following day, you will receive an email noting whether your information was verified or rejected at that time.

Additional Information

If you need help filling out this form, please contact the Campus COVID Call Center: 734-936-7000. Call center hours are 8AM–5PM Monday – Friday; 9AM–6PM Saturday & Sunday.