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 your manager has this form so they can account for this Flu vaccine on the
Flu Web site.
MANAGERS: PLEASE FORWARD ALL CONSENTS, DECLINATIONS &
ELSEWHERE DOCUMENTS TO EMPLOYEE HEALTH BY APRIL 1, 2016.