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.
I hereby grant Pomona College, working with healthcare provider Hamilton Healthbox (HHB), authorization to confirm my vaccination booster information via the state vaccination registry.*
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.
Please review this form submission for the individual named above. If you identify any errors or discrepancies, you may: