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2025 Flu Vaccination Attestation

Link to Exception Forms

First Name

Last Name

Email

Are you requesting an exemption? If so, please upload an exemption form for each facility you are credentialed at. *

Yes

No

Date of Flu Vaccination or Completion of Exemption Form(s) * required

Site(s) Credentialed At: * Required

Stoughton

Edgerton

Beloit

Fort

HFM

Northwestern

NEMHS

JCRHC

MMC

Proof of Vaccination or Exemption Form(s)

Upload File

Please upload Exemption Form(s) for each facility, if applicable.

I attest to uploading proof of flu vaccinaton or flu vaccination excemption form.Link to Exemption Forms

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