Employee Vaccination Status

Please complete the form to disclose your current vaccination status.

All Fortifi Bank employees are required to disclose their vaccination status against COVID-19. Employees may request an exception on the basis of a medical condition or sincerely-held religious belief.

Acceptable proof of vaccination includes documentation provided by a tribal, federal, state, or local government, or a health care provider, that includes an individual’s name, date of birth, type of COVID-19 vaccination given, date or dates given, depending on whether it is a one-dose or two-dose vaccine, and the name and location of the health care provider or site where the vaccine was administered. Documentation may include but is not limited to a COVID-19 vaccination record card, a copy or digital picture of the vaccination record card, or a print-out from the Wisconsin Health Authority’s immunization registry.

HIPAA Statement
Fortifi Bank is a hybrid entity under HIPAA (Health Insurance Portability and Accountability Act 1996). This designation requires the Bank to collect a limited data set of protected health information to meet City, State, and Federal mandates. To protect the privacy of personal health information under HIPAA, the Bank will only use this collected information for tracking compliance with the COVID-19 vaccination mandate; securely retain this information in compliance with HIPAA safeguard requirements; only allow access to this information by authorized Bank users that have “need to know” responsibilities; train and monitor authorized users who have access to your protected health information (PHI); not disclose this information without your prior consent, unless mandated by State or Federal health authorities; notify you of unauthorized disclosure should that occur; and annually assess Bank HIPAA safeguards, training, and how to continuously improve the Bank’s HIPAA compliance program.