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.
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.