Building Installation Group I, Inc.

COVID-19 Vaccine Form

Thank you for filling out this proof of vaccination form. At this time, Building Installation Group, I does NOT require its employees to be vaccinated. However, some of our customers require all individuals who step foot on a job site to be vaccinated. For those customers who do require vaccination, we will be required to schedule only employees who have been vaccinated on those particular jobs.

If you have any questions regarding why you need to provide this information, contact David Martin, david.martin@buildinstall.com or call 877-244-9310. Thank you.

Please understand that if you fail to respond to this form or indicate that you are unvaccinated the company will not be able to assign you to those job sites that require all contractors to be vaccinated. All information provided regarding your vaccination status will remain confidential.

Employee Information

First Name

Last Name

Phone Number

Email Address

What is your vaccination status?

Vaccination Information

Which COVID-19 vaccine did you receive?

Which date did you receive the first dose?

What date did you receive the second dose? (Note: Leave blank if you got Johnson & Johnson)

What date are you scheduled to receive the second dose? (Note: You will need to resubmit this form after receiving the second dose)

If you got a booster shot, what date did you get a booster shot? (Note: You will need to resubmit this form after receiving the booster.)

Please upload a picture of your vaccination card OR a screenshot from your provider's online patient portal.

Maximum file size: 2.1MB

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