Submit Proof of Flu Vaccination

Use this form if you received your flu vaccine outside of Texas Children's Hospital.

Employee Information

Legal First Name

Last Name

Date of Birth

Employee ID

Department

Work Email

Work Building / Location

Leader Legal First and Last Name

Which shift do you work?

Days Evenings Nights

Preferred number to call you?

Work Cell Other

Vaccination Details

Date Vaccine Received

Vaccine Provider / Location

Vaccine Brand

Vaccine must have been received within the current flu season per Employee Health policy.

Documentation Upload

Attach a photo or PDF of your vaccination documentation.

📄

Drag and drop your file here

JPEG, PNG, TIFF, or PDF (max 50 MB per file)

I certify that the information and documentation submitted are true and accurate.

Submissions are routed to an automated review queue. Employee Health will contact you if additional information is needed.

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Thank you for submitting your documentation.

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