COVID-19 Vaccine Information Community

COVID-19 Vaccine Information

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

If you do not have a copy of your COVID-19 Vaccination Record Card, you may request assistance in acquiring appropriate proof of your vaccination from Hamilton Healthbox (HHB), the healthcare provider working with the College on COVID-19 testing and related-policies. To do this, please complete all fields, select “I accept” under both statements and click “Submit Form” to complete your request. HHB will confirm your vaccination status through the state vaccination registry and share that record with the College.

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*

Email*

Preferred Phone Number*

Role on Campus*

Course Auditor Community Partner Guest/Visitor High School Student

High School Name*

Pomona College Host or Sponsor*

Host or Sponsor Email*

Purpose of Pomona College Visit*

Course Information

Start Date*

End Date*

Course Number/Title*

Instructor Name*

Enrollment Approval*

No File Chosen

File uploads may not work on some mobile devices.

Please upload a copy of your approval to enroll in course (email from faculty is sufficient)

Additional Demographics

Date of Birth*

Gender*

Male Female Non-binary

Are you Hispanic or Latino?*

Yes No

Race/Ethnicity*

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other

Are you a U.S. Citizen?*

Yes No

Country of Citizenship*

High School Student/Course Auditor Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Final Vaccination Date*

Should be the date of 2nd dose unless you received a single dose vaccine

Vaccination Record Card

No File Chosen

File uploads may not work on some mobile devices.

I understand that my information and vaccination image may be sent to Hamilton Healthbox (HHB, Pomona College’s medical partner) for further review.*

I accept I do not accept

I hereby certify that I have submitted a copy of my completed Vaccination Record Card.*

I accept I wish not to provide the College with a copy of my Vaccination Record Card. I understand that until I provide the College with this information, I am not permitted to participate in any College programs.

HHB Nurse Vaccination Record Confirmation

Please verify the final vaccination date and/or upload a copy of the COVID-19 Vaccination Record Card for the individual named above and mark the Confirmation Status field accordingly. Once your review is complete, this submission will be returned to the Initial Reviewer for a final decision.

Confirmation Status*

Confirmed Unconfirmed Other

HHB Nurse Comments

Vaccine 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 be instructed to create a new submission)
Forward the submission to the HHB Nurse for confirmation of the individuals vaccination record by marking the Review Status as Needs HHB Confirmation

If the Review Status for the submission is marked as Needs HHB Confirmation, it will return to your workspace for a final review after the HHB Nurse has completed the confirmation step. You may then update the Review Status field based on the feedback provided by HHB.

Vaccine Info Review Status*

Approve Reject Needs HHB Confirmation Needs Event Planning Confirmation

Reviewer Comments

The submitter will receive an email notification containing your comments above

Guest/Visitor Review

Guest/Visitor Review Status*

Confirmed Unconfirmed

Guest/Visitor Review Comments