COVID-19 Booster Information WF

COVID-19 Vaccine Booster Information

To help Pomona College set continued COVID-19-related safety policies, the College wants to track COVID-19 vaccination boosters in its community. Please complete all required fields below and select “choose file” to upload a photo of your COVID-19 Vaccination Booster Record. Please leave out any additional medical information from your submission. Once you have done this, please select “I accept” under the statement below and click “Submit Form” to complete the submission.

Hamilton Healthbox (HHB), will confirm your vaccination booster status through the state vaccination registry. This information will be treated as a confidential medical record and will only be disclosed and used by Pomona College and its COVID-19 health and safety partners or as otherwise required by law.

First Name*

Middle Initial

Last Name*

Pomona ID*

Alphanumeric username (e.g. abcd4747 or abcd2021)

Pomona Email*

Preferred Phone Number*

Role*

Faculty Staff

Department*

Booster Date*

Should be the date of your booster dose

Booster Record Card*

No File Chosen

File uploads may not work on some mobile devices.

Date/Time

I hereby grant Pomona College, working with healthcare provider Hamilton Healthbox (HHB), authorization to confirm my vaccination booster information via the state vaccination registry.*

I accept

HHB Nurse Vaccine Booster Info Review

Per Pomona College Human Resources, please verify the vaccine booster date and/or upload a copy of the COVID-19 Vaccine Booster Record for the individual named above and mark the Confirmation Status field accordingly. Once your review is complete, this submission will be sent to HR for a final review.

Confirmation Status*

Confirmed Unconfirmed Other

HHB Nurse Comments

HR Vaccine Booster Info Review

Please review this form submission for the individual named above. If you identify any errors or discrepancies, you may:

Manually correct them on behalf of the individual and complete the workflow by marking the Review Status as Approve
Invalidate the submission and trigger an email notification to the individual with your comments by marking the Review Status as Reject (NOTE: This will also complete the workflow. The individual will receive an email with instructions to create a new submission)

Review Status*

Approve Reject

Reviewer Comments*

The submitter will receive an email notification containing your comments above