Offsite Flu Verification Form

If you received a flu vaccine for the 2020-2021 flu season from a healthcare professional, complete the Offsite Flu Verification Form. Click on the box below to download and print the form. Forms must be submitted by November 30, 2020.

Before you submit your form, make sure you have:

To submit your form, complete the fields below. Click "Select a File" to load your document(s), then click the “Upload Form” button.

FORMULAIRE DE VÉRIFICATION DE LA GRIPPE HORS SITE

Si vous avez reçu un vaccin contre la grippe pour la saison grippale 2020-2021 d'un professionnel de la santé, veuillez remplir le formulaire de vérification de la grippe hors site. Cliquez sur la case ci-dessous pour télécharger et imprimer le formulaire. Les formulaires doivent être soumis avant le 30 novembre 2020.

Avant de soumettre votre formulaire, assurez-vous d'avoir: 

Pour soumettre votre formulaire et documentation(s), veuillez remplir les zones de texte ci-dessous. Veuillez cliquer 'Select a File' pour charger vos documents, puis cliquer sur le bouton 'Upload Form'. 

 

Health Screening Form (U.S. Associates)

Completed form is due on or before November 30, 2020 to be guaranteed updated incentives on your first 2021 paycheck. Date of test must be within the past 12 months of your submission.

Before you submit your form, make sure you have:
  • Completed top section of form
    • Step 1: Fill out your information AND include email address.
    • Step 2: Ensure YOU have signed your form. Without your signature, this form will not be accepted.
  • Ask your physician to complete Step 3 in its entirety

To submit your form, complete the fields below. Click "Select a File" to load your document(s), then "Upload Form" button.

 

Personal Details
 Date Format: YYYY-MM-DD
Upload Files

For assistance, please contact US Wellness at 855-279-3246.