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 leave out any additional medical information from your submission. If you have a copy of your COVID-19 Vaccination Record Card, you may upload it along with the other requested information by clicking the “Choose File” box below.
If you do not have a copy of your COVID-19 Vaccination Record Card to upload and will accept the College’s help in getting confirmation of your COVID-19 vaccination, please check the “I accept” box below. This will allow Hamilton Healthbox (HHB), the healthcare provider working with the College on COVID-19 testing and related-policies, to confirm your COVID-19 vaccination date(s) through the state vaccination registry and share the records with the College.
This information will be treated as a confidential medical record. This information 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 information via the state vaccination registry.*
I hereby certify that I have submitted a copy of my completed Vaccination Record Card.*
Per Pomona College Human Resources, 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 HR for a final review.
Please review this form submission for the individual named above. If you identify any errors or discrepancies, you may:
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.