University of California Davis Medical Center, Employee Health Services
2221 Stockton Boulevard, Cypress Building Suite A, Sacramento, CA 95817
916-734-3572 Fax 916-734-7510
I have had a flu shot elsewhere for 2015-2016
I had the vaccine elsewhere at my PCP, Costco, or a Pharmacy. Please attach proof
of vaccination to this form.
Location where vaccinated:
Print name:
Date vaccinated:
Signature:
(Legal name; including entire hyphenated name)
Date of Birth:
PPS ID:
Date:
(# on your ID badge)
You will be counted as vaccinated !!
Ensure that SOM Registrar’s Office has this form so they can account for this flu
vaccine on the Flu Website.