vaccination form - RoadSafe Traffic Systems, Inc.

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RoadSafe Vaccination Form

Thank you for sharing your COVID-19 vaccination status with RoadSafe. The information collected here is secure and is not a part of your employee file. RoadSafe will use this data to:
Comply with certain State or Federal OSHA mandates regarding our pandemic practices.
Understand COVID-19 vaccination rates at our locations and what further safety precautions need to be implemented.
Appropriately staff our customers’ projects that are requiring “fully vaccinated” employees only.
Be able to better perform contact tracing. For instance, if you or one of your co-workers tests positive for COVID-19 or has a “close contact” with someone with COVID, employees that are vaccinated have different protocols, can return to work faster, and don’t necessarily have to quarantine like unvaccinated employees.
This process should only take a few minutes. You will be asked to input the type of vaccine you had, when you received your shot(s) and to upload a picture of your proof of COVID-19 vaccination.
If you have any questions, please reach out to the RoadSafe Human Resources Department at (312) 800-9219.

Start

How would you like to be contacted?

While we don’t anticipate needing to contact you, if we need to reach you, what is the best way?

Phone

Email address*

Phone*

Select your branch location*

Select your name - WV - Hurricane*

Select your name AZ - Phoenix*

Select your name - CA - Corona*

Select your name - CO - Denver*

Select your name - Corporate*

Select your name - FL - Daytona Beach*

Select your name - FL - Miami*

Select your name - FL - Tampa*

Select your name - FL - W. Palm Beach*

Select your name - GA - Atlanta*

Select your name - GA - Augusta*

Select your name - IL - East Peoria*

Select your name - IL - Romeoville*

Select your name - IN - Evansville*

Select your name - IN - Lafayette*

Select your name - KS - Benton*

Select your name - KS - Wichita*

Select your name - LA - Shreveport*

Select your name - MA - Avon*

Select your name - MD - Cumberland*

Select your name - MS - Jackson*

Select your name - NC - High Point*

Select your name - NC - Raleigh*

Select your name - NV - North Las Vegas*

Select your name - NV - Sparks*

Select your name - OH - Columbus*

Select your name - OK - Tulsa*

Select your name - OR- Lake Oswego*

Select your name - PA - Altoona*

Select your name - PA - Gibsonia*

Select your name - PA - Watsontown*

Select your name - PA - York*

Select your name - SC - Columbia*

Select your name - TN - Powell*

Select your name - TX - Corpus Christi*

Select your name - TX - Houston*

Select your name - TX - Laredo*

Select your name - UT - Bluffdale*

Select your name - VA - Roanoke*

Select your name - MD - Washington*

Select your name - UT - Salt Lake City*

Select your name - NC - Apex*

Select your name - CA - Sutter*

Name*

First

Last

Employee number (optional)

Status*

New Employee

Existing Employee

Branch location*

Have you been fully or partially vaccinated against COVID-19?*

Yes

Which vaccine were you given?*

Pfizer

Moderna

Johnson & Johnson

How many vaccination shots have been administered to date?*

Date Vaccinated*

Date of First Vaccination Shot*

Date of Second Vaccination Shot*

Date of Third Vaccination Shot

Please upload your vaccination card here*

Please upload a copy of your COVID-19 vaccination record(s). Acceptable forms of vaccination records are:
A picture of the CDC card issued to you when you got your shot(s)
A copy of documentation of COVID-19 vaccination from a health care provider who administered your shot
Official state records of COVID-19 vaccination. Several states offer this to their residents. For instance, for CA residents, you can download your record from myvaccinerecord.cdph.ca.gov.
Do not provide any medical information other than proof of the COVID-19 vaccination(s).

This field should be left blank

COVID-19 vaccination form