First Name: Date of Birth

FORM FOR SUBMITTING FLU VACCINATION RECORD

2017 - 2018

LAST NAME:

FIRST NAME: DATE OF BIRTH:

/ / /

CONTACT INFO – Phone#: Email:

( / ) / - / Or

Are you a Hartford Healthcare Employee?

 Yes - Employee ID#: / 1 / 0 / 0 / 0
 Hartford Hospital /  HHC System Support (SSO) /  Windham Hospital /  Southington Care Ctr
 Institute of Living /  HHC Medical Group /  William Backus Hospital /  The Orchards
 Jefferson House /  HHC Laboratories /  HOCC – New Britain /  Mulberry Gardens
 Cedar Mtn Commons /  HHC at Home /  HOCC - Bradley /  Natchaug Hospital
 HH Rehab Network /  HHC Independ. at Home /  Senior Care Services /  Rushford Center
 HH MOB /  Midstate Medical Center /  Other______
 No - What is your role?
 Attending Physician or PA, APRN - Practice: ______& NPI ______
 UCONN Resident  Other Residency/Fellowship Program: ______
 Student-Type:  Nursing  Medical  Pharmacy  SRNA  Other ______
 Volunteer - Facility:______
 Contractor / Other – Name of Company: ______
Confirmation of Vaccination
I verify that I have received this season’s flu vaccination elsewhere and have attached documentation.
Date of vaccination: / / / /
Signature
Please bring this form & a copy of your flu documentation to any HHC sponsored flu clinic or Employee Health Department. You can also submit by fax, interoffice mail or email to the following:
- / Hartford Hospital employees – Send to Occupational Health; Fax: (860) 545-2137; Email:
- / Hospital of Central CT New Britain & Bradley employees – Send to Employee Health; Fax: (860) 224-5745
- / Midstate Medical Center Employees – Send to Employee Health; Fax: (203) 694-7625
- / HHC at Home Employees – Send to Infection Control; Fax: (860) 493-5923 or by Tiny scan
- / HHC Medical Group Employees – Send to HHC Occ Health in Wethersfield; Fax: (860) 787-5789
- / Senior Care Services Employees – Bring to flu clinics at facility or send to Senior Care Services; Fax: (860) 426-0506
- / William Backus Hospital & Windham Hospital employees – Send to Employee Health; Fax: (860) 892-6994
- / Natchaug Hospital Employees – Send to Janette Cawley, Mailbox 44 or if off site give to practice manager to send
- / Rushford Employees – Send to HR Department on Paddock Ave; Fax: (203) 634-7088
- / System Support Office (SSO) & HHC laboratories employees – Send to the location that you work at or affiliated with