UK HealthCare COVID-19 Vaccination Mandate Toolkit


  1.  Frequently Asked Questions
  2.  Vaccination Self-Attestation / Self-Report
  3.  Vaccination Compliance Tracking
  4.  Exemption Request and Process
  5.  Surveillance Testing Protocol PAUSED* see note below
  6.  Vaccine Resources (lost card, need the vaccine, specialty-specific resources, education)
  7.  How to Sign Up for MyChart
  8.  COVID-19 Policy (A03-125)
  9.  Corrective Action
  10.  Written Warning Templates
  11.  Pre-Employment COVID Vaccination Process

COVID vaccination requirement

Effective September 15, 2021, UK HealthCare required COVID vaccination for providers, staff and new employees, with approved exemptions for religious and medical reasons. On Nov. 4, 2021, the Centers for Medicare & Medicaid Services (CMS) issued a stricter mandate requiring those who work at health care facilities to be fully vaccinated against COVID-19 or receive an approved  medical or religious exemption. Under the CMS rule, unvaccinated workers without an exemption are not allowed to “provide any care, treatment or other services for the facility and/or its patients.”

CMS deadlines in their vaccination mandate are:

  • First dose or exemption request by Feb. 12, 2022.
  • Second dose or approved exemption by Mar. 15, 2022.

Refer to our COVID-19 Policy for more information.

Frequently Asked Questions

Your questions answered about the vaccination requirement are below.  
Additional questions about the vaccine have been answered and are posted on the FAQs: COVID-19 Vaccine Information page.

Q: Where can employees go to schedule and receive the vaccine?

A: Employees should go to to schedule a vaccination. UK HealthCare Pharmacy Services is offering vaccinations at multiple locations, including University Health Pharmacy on campus. Information is available at the website, and you can choose the location you prefer.

Q: Will the employee be able to choose the manufacturer of the vaccine?

A: Yes. UK HealthCare offers the Pfizer and Moderna vaccines and you may specify which you prefer. We no longer have the Johnson & Johnson vaccine available. If you prefer a vaccine other than Pfizer or Moderna, you are welcome to get it elsewhere and provide proof that you received it.

Q: Is the Johnson & Johnson vaccine an available option for unvaccinated employees who would prefer it over the Pfizer or Moderna vaccines? Will this fulfill the requirement?

A: UK HealthCare no longer offers the Johnson & Johnson vaccine. Those who prefer this vaccine may receive it elsewhere and supply proof of vaccination to fulfill the requirement.

Q: Am I, as a UK HealthCare supervisor and/or a faculty member supervising residents or students in the clinical environment, allowed to ask the COVID-19 vaccine status of my employees or students/residents? Is this a HIPAA violation?

A: Yes, you may ask. No, this is NOT a HIPAA violation. HIPAA protects medical records, but it excludes employment records from these protections. There is nothing in HIPAA that prohibits an employer from asking an employee to provide proof that they have been vaccinated.

Supervisors, however, are NOT PERMITTED to check the Epic medical record system to validate the vaccine status of their employees, students or residents. Information stored in Epic is protected health information under HIPAA and is not to be used to validate this vaccine-status process. The privacy team will continue to monitor accesses in Epic during this time, and misuse of Epic may lead to corrective action for employees who access this information in Epic.

Q: Are vaccinations received through UK HealthCare documented somewhere? 

A: Immunizations are reported to the Kentucky Immunization Registry.

Q: I received my second vaccine at Kroger field but it does not show up on my chart in Epic. Will employee records be updated?

A: Vaccinations received at Kroger Field do not automatically appear in the Epic EHR. The records are held by the Kentucky Immunization Registry. If you need a copy of your CDC vaccination card, see below for the process to request one.

Q; Where/how can we get replacement vaccination cards?

A: If you’ve lost your COVID-19 vaccination card, you can retrieve proof of your immunization by contacting the Kentucky Immunization Registry. The KIR will help, whether you’ve had just the first of a two-dose vaccine or are fully vaccinated. Also, if you received a vaccine from your primary care provider, they might be able to issue a replacement card.

To contact the Kentucky Immunization Registry about replacing a lost COVID-19 vaccination card, call 502-564-0038 or email You can also visit the Kentucky Immunization Registry website by clicking here.

Q: Are there resources available we can refer people to who are hesitant about the vaccine? For instance, people have episodes of anxiety when considering getting it.

A: Information about the vaccines and the incidence of adverse reactions can be found here:

Q: If you work from home ONLY, do you still have to get vaccinated?

A: Yes, all employees are required to be vaccinated against COVID-19. Think about your health and your family’s health and the safety of those around you, get vaccinated. The data supports the vaccine.

Q: Will incoming and other travel RNs be required to be vaccinated?

A:  Yes. We will require it to protect our patients and people. These individuals have also been required to have flu vaccines.

Q: Will College of Medicine faculty and staff working in clinical settings be required to be vaccinated? 

A: College of Medicine faculty and staff who work in clinical settings are required to follow the UK HealthCare COVID-19 vaccination policy.

Q: Where can you find the declination form and will the form have the criteria for conclusion of religious and medical conditions?

A: The Exemption Request and Process section of the managers toolkit outlines how to submit a request to decline the COVID vaccine and provides a link to print the provider letter which should be completed and uploaded through the MyChart exemption process.

Q: Many will claim or state a declination for medical reasons. What will be the process for assessing the validity?

A: We have created a form letter your provider must utilize.

Q: We do not do a good job at following up on declination for flu vaccine, let alone those who do not get it and don’t wear proper PPE like they are supposed to.

A: Our flu vaccination rate is over 98%, so we hope it will work with this as well. If you see someone not following hand hygiene or mask wearing, contact Kimberly Blanton and the IPAC team. If we have people not following protocol, we will try to work through it and talk to them for the safety of others.

Q: Will employees be terminated after receiving a written warning for non-compliance with the COVID-19 required vaccination?

A: If an employee has chosen not to be in compliance with the required COVID-19 vaccination and did not receive an exemption via the “Employee Health Immunization Declination” process, the employee received a written warning. Employees in this situation have been placed on a COVID-19 testing protocol. If an employee chooses not to comply with the testing protocol, other measures, including the possibility of corrective action, may be implemented.

Q: What if somebody has seizures from fevers and therefore avoids getting the vaccine, is it possible to setup an overnight observation for such cases?

A: Talk to your personal medical provider about your concerns. This may qualify as a medical exemption. If you do get the vaccine, you are welcome to remain at the site for as long as you wish to ensure you do not have a reaction, but we do not have a process for keeping people overnight.

Q: Will there be a standard process to ensure students are vaccinated before rotating?

A: We will work with the health-profession college deans. They are to verify their students are vaccinated and that they complete the daily screenings as they were doing before. It is more than just UK students, it includes college students from other places as well.

Q: What if I have an adverse reaction to the vaccine? Will UK be responsible financially since it’s a mandate?

A: There will be paid time off to get the vaccine and recover if needed.

Q: How long will a new employee have to get the vaccine?

A: New employees should schedule the COVID-19 vaccine as they come in and follow other standard new employee processes and requirements.

Q: How do managers request and receive COVID-19 vaccination status stickers for fully vaccinated employees? 

A: UK HealthCare leaders, please fill out this form to request stickers indicating COVID-19 vaccination status for your department’s employees. Log into the Vaccination Compliance Tracker, and confirm “compliant – vaccinated” by an employee’s name before you request and issue a sticker. Only issue stickers to fully vaccinated employees. Pick up stickers from the location you selected on the form. If you hire a new employee after this time, you may request additional stickers by contacting Leslie Hargis.

Q: How will those required to test weekly for COVID make appointments? 

A: Those required will use MyChart to schedule weekly testing appointments. When logged in to MyChart, after selecting “Visits,” select “Employee COVID testing,” which will allow you to select your preferred testing location. Scheduling an Appointment for COVID Surveillance Testing

Q: Do unvaccinated employees who work remotely from home have to test weekly? 

A: Unvaccinated employees who work remotely from home are not required to test regularly for COVID unless they will be coming to a UK HealthCare facility for work-related business. If planning to be on-site, a COVID test at one of the designated sites with the negative result is required 96 hours or less prior to the visit. If the employee lives more than 50 miles away from Lexington, they may submit the test result directly to Infection Prevention & Control by:

The negative test result must be uploaded prior to the visit. Managers will check the Vaccination Compliance Tracker prior to an unvaccinated remote worker being allowed to enter UK HealthCare facilities.

Q: If someone is on Family Medical Leave and missed the Sept. 15 deadline, will they receive corrective action for failure to comply with the vaccine requirement?

A:  No. If an employee has been on FML and has not met the requirements of the COVID-19 policy by Sept. 15, they will not be issued corrective action. The employee’s manager should work with Employee Relations to develop a plan to get them in compliance upon their return to work.


Vaccination Self-Attestation / Self-Report

To upload proof of COVID-19 vaccination, use the UK Health Corps Self-Report Tool. UK HealthCare has partnered with UK campus Health Corps for its vaccination self-reporting tool to document faculty and staff vaccination status. This process meets UK HealthCare Corporate Compliance standards for privacy and security.

The following groups are required to be fully vaccinated against COVID-19 or have an approved declination.

  • UK HealthCare employees (including: STEPS and remote employees)
  • All faculty and staff (including graduate medical education) of the colleges of Medicine, Nursing, Dentistry, Pharmacy, Health Sciences and Public Health who conduct work in a UK HealthCare facility;
  • Kentucky Medical Services Foundation, Eastern State Hospital and Central Kentucky Management Services employees;
  • Campus shared services who work within a UK HealthCare facility and contracted staff;
  • UK students who will be learning in a UK HealthCare facility; and
  • Volunteers

Faculty and staff who have received COVID vaccination should use the UK Health Corps Self-Report Tool to document their vaccination status. Click here to view a video demonstrating how to use this self-report application. Note: Video was produced for campus use. UK HealthCare providers and staff will need to submit documentation for UK HealthCare purposes.

Upload proof of vaccination to UK Health Corps Self Report 

Please have your COVID-19 vaccination documentation ready in an image file (jpeg, png, etc.). You will be prompted to upload it once you log in. You can perform this process from your desktop or mobile device.

When you receive a booster, please upload your documentation to the UK Health Corps Self-Report Tool.

The information you provide will flow into the UK HealthCare Vaccine Compliance Tracking tool (VCT), created for the use of managers, supervisors, Infection Prevention & Control and Employee Health to validate and track compliance with the vaccination mandate and/or testing protocol required of all unvaccinated employees listed in the inclusion groups.

NOTE: Users will need their linkblue ID in order to sign into the application. For assistance with your linkblue ID:

  • Campus IT Help Desk (859-218-4357) can help campus shared services and students.
  • UK HealthCare IT Service Desk (859-323-8586) can assist all others.

Contractual Staff/Vendors

The reporting and tracking mechanism for contractual staff/vendors (i.e. Agility, Stryker, Compass One – Crothall/Morrisons, Reef, etc.) is the responsibility of the contracting agency. Vendors can utilize Vendormate. The reporting of status or attestation should be provided to UK HealthCare as needed on demand. It is the agency’s responsibility to utilize Vendormate if applicable.

Non-UK Student/Learners

The reporting and tracking mechanism for non-UK student/learners is the responsibility of the college/school. The reporting of status or attestation should be provided to UK HealthCare as needed on demand. The office of Observation and Learning Experience or department-specific advisor is responsible for maintaining vaccination requirements, declination documentation, and testing requirements as they relate to the COVID-19 vaccination requirement.


Vaccination Compliance Tracking

Read the Vaccination Compliance Tracking instructions.

Click here for the Vaccine Compliance Tracker application

NOTE:  An employee is considered fully compliant with our COVID vaccination requirement 14 days after their last COVID-19 vaccine in the series.

  • If the employee received the Janssen/Johnson & Johnson vaccine, they are considered fully compliant 14 days after the single dose.
  • Those receiving Moderna and Pfizer vaccines are fully compliant 14 days after their second dose.

The Vaccine Compliance Tracking tool has been enhanced to reflect this fully compliant status. You will notice a new status of “In Process” in your VCT view. If an employee has received only a part of the vaccination series OR the 14-day post completion window has not expired yet, the system will now list their status as “In Process.”

There is no corrective action attached to “In Process” status and the employee will be enrolled in the testing protocol until their 14-day window has expired.

At that time, when the employee is now considered “fully compliant,” the system will change the status to “compliant – vaccinated” and the employee will be removed from the testing protocol automatically.

Only those “fully compliant” with the COVID vaccination requirement should receive or wear a COVID vaccination sticker on their badge.

Exemption Request and Process

Important Note 

If you previously refused the vaccine or if you previously requested a medical exemption, you will need to either get your first dose of a COVID vaccine (or the single Johnson & Johnson dose) or file for a new exemption by February 12, 2022. CMS mandate medical exemption requirements are more stringent than UK HealthCare previously imposed, and CMS does not allow for unvaccinated, nonexempted health care workers to continue to render services for UK HealthCare past that date.

  • If you have already submitted a formal medical declination, you may need to take additional action if your original request does not meet CMS guidelines. You will be notified if this is the case.
  • If you previously requested and were granted a religious exemption, you do not need to take further action, other than complying with the COVID-19 testing protocols for unvaccinated employees.
  • If you previously requested a pregnancy deferral, you will need to take additional action to request a medical exemption. However, please be aware that even if you were previously granted a pregnancy deferral, that deferral might not withstand scrutiny under the federal standards for a medical exemption. Therefore, you may request a new medical exemption using the medical exemption provider letter linked below, or request a religious exemption if you have a sincerely held religious belief against taking the vaccine.

Requesting medical or religious exemption from vaccine requirement
If you would like to request an exemption (religious or medical) from the COVID vaccine mandate, follow the instructions outlined below.

  1. If requesting medical exemption, print and complete the provider letter. The signed form will need to be uploaded through MyChart exemption process.
  2. All requests for exemptions will be processed electronically, through Epic and your MyChart account. How to Access and Complete an Immunization Declination Request Form – UK HealthCare
  3. Information on how to sign up for MyChart is included here. You do not need to be a patient of UK HealthCare to have a MyChart account.

If an exemption is granted, the unvaccinated employee shall be subject to certain conditions, including regular COVID-19 testing, provided by UK HealthCare.


Surveillance Testing Protocol

NOTE: See April 12, 2022, announcement. Weekly surveillance testing is not required at this time.

Weekly COVID surveillance testing for unvaccinated UK HealthCare employees began Sept. 16.

UK HealthCare providers and staff who have an approved exemption will be required to test frequently. The Vaccine Compliance Tracker application will automatically notify the employee of their inclusion in the testing protocol and how/where to schedule the testing.  

Those who submitted a declination request can expect a response to their request via their MyChart portal.

Employee Health is not conducting this weekly testing.

There will be designated testing locations for employees. Individuals with exemptions who work on-site in any UK HealthCare facility will be tested weekly.

All testing must be PCR test only and completed per timing requirement outlined. Appointments for testing should be scheduled via MyChart. See: Scheduling an Appointment for COVID Surveillance Testing

Follow this link for full details of COVID-19 Surveillance Testing Protocol.

The UK HealthCare deadline to initiate a complete series of vaccination is Feb. 12, 2022; required testing of the partially vaccinated UK HealthCare providers and staff continues after that deadline until two weeks post your second dose.

*If an employee is on an approved absence (family medical leave or vacation leave) for the entirety of their work week, the employee is exempted from the required testing protocol for their work week. The employee must obtain a negative PCR COVID test within 96 hours of their return to work.  If the employee is absent for only part of their work week, the employee is expected to comply with the testing protocol for their work week.


Vaccine Resources

Lost vaccination cards?
If you’ve lost your COVID-19 vaccination card, ask the Kentucky Immunization Registry for your record. To retrieve your immunization records, complete the KYIR Release of Immunization Record and fax the completed form to their helpdesk at 502-564-4760.

Resources for those with questions about COVID vaccination

Go to to request vaccination.

Click here to see the three UK HealthCare locations currently available.


How to Sign Up for MyChart

Sign up for MyChart at


COVID-19 Policy

COVID-19 (A03-125) (must have access to UK HealthCare Policy Web)


Corrective Action

Required COVID vaccination

Any employee fully vaccinated under UK HealthCare’s original vaccine mandate is still compliant under the CMS vaccine mandate. Employees must continue to upload any additional vaccine doses to the UK Health Corps Self-Report Tool.

If not fully vaccinated, the deadline to submit proof of the first dose or request an exemption is February 12, 2022. Proof of the second dose or an approved exemption must be submitted as of March 15, 2022. According to COVID-19 Policy, if proof of vaccination is not provided, or if a request for an exemption is not filed by the stated deadline, the health care worker will be assumed to have not timely completed the vaccine requirement.

If an employee is marked in Vaccine Compliance Tracker as in any of these status categories on February 13, 2022, they cannot work and will be placed on Administrative No Pay:

  • NON-COMPLIANT – DENIED EXEMPTION = denied medical exemption without a provider letter.
  • NON-COMPLIANT – REFUSED = refused the vaccine with no medical/religious reason.
  • NON-COMPLIANT = employee did not submit anything to the self-report tool and also did not submit a declination.

If any employee is marked in Vaccine Compliance Tracker as in any of these status categories on March 16, 2022, they cannot work and will be placed on Administrative No Pay:

  • IN PROCESS = only have one dose vaccine OR less than14 days since vaccine.
  • NON-COMPLIANT – ACKNOWLEDGED EXEMPTION = provider letter stating a medical reason but did not qualify as an approved exemption per CDC guidelines.
  • NON-COMPLIANT = employee did not submit anything to the self-report tool and also did not submit a declination.

Staff corrective action will be issued by the manager or supervisor to the employee. The employee will be given a copy and a copy will be placed in the employee’s personnel file.

If an employee chooses not to be in compliance with the required COVID-19 vaccination (including failure to submit proof of vaccination) and does not receive an exemption via the “Employee Health Immunization Declination” process, corrective action will be issued.

Corrective Action – Required COVID-19 Vaccination

Please refer to the steps outlined on the charts linked below to understand how corrective action will be applied.

Also, please see CMS Vaccination Mandate Corrective Action Frequently Asked Questions

Corrective Action – Required Surveillance Testing Protocol

Unvaccinated providers and staff with approved exemptions must complete surveillance testing weekly.

For providers and staff who fail to comply with requirements of UK HealthCare’s COVID-19 Policy – specifically addressed here are failure to follow the surveillance testing protocol and/or mask requirement without a validated reason* – the following steps of corrective action will apply: 

UK HealthCare regular employees UK HealthCare PRN/On Call/STEPs/Temp
Offense 1)  Written Warning – Memo Offense 1) Written warning – Memo
Offense 2)  Probation for 90 days (no merit increase, inability to transfer, inability to take vacation) – Memo Offense 2) Move to termination, ineligible for rehire (violation of university or department rule)
Offense 3)  Suspension (one day without pay) – Memo
Offense 4)  Termination

*validated reasons include Family Medical Leave, military leave

Providers will be subject to the disciplinary process outlined in the medical staff bylaws.

Questions about the corrective action process can be directed to or UK Employee Relations, 859-257-8758.


Written Warning Templates for Surveillance Testing

NOTE: Customize the letterhead to your department by clicking “View” in the top application bar and selecting “Header and Footer.”

Written Warning Noncompliant with Testing and-or Masking

Written Warning Noncompliant with A03-125 – PRN On-Call

Probation Noncompliant with Testing and-or Masking

Suspension Noncompliant with Testing and-or Masking


Pre-Employment COVID Vaccination Process

COVID vaccination is required of all new employees, and has been posted in all UKHC job descriptions since September 8, 2021. Individuals accepting a job offer after September 15, 2021, are required to submit their vaccination status or receive an approved medical or religious exemption as a condition of employment.

Read the COVID-19 Vaccination Pre-Employment Protocol for Hiring Officials


For questions about this toolkit, contact