Student Vaccination Disclosure Form

Coronavirus

SECTIONS

Report your COVID-19 Vaccination Status

For Students

The information requested on this form is collected for the purpose of notifying WRH Employee Health of your COVID-19 vaccination status and will be kept private and confidential.

Questions or issues submitting this form? Please email VaccinePolicy@wrh.on.ca

Download a digital copy of your COVID-19 vaccination receipt here.

Demographic Information

*First Name:

*Last Name:

Date of Birth (not mandatory):

*School Email Address:

Phone Number:

*Student Number:

*School Attending:

*Program:

COVID-19 Vaccine Status

This information will be reviewed by Employee Health and kept private and confidential.

*Please choose ONLY ONE option below to indicate details from your COVID Vaccine status:

Please choose ONLY ONE option below to indicate details from your COVID Vaccine statusA. I have received 1 dose of a Health Canada approved COVID-19 vaccine (documentation is required).
B. I have received 2 doses of a Health Canada approved COVID-19 vaccine (documentation is required).
C. I have received 3 doses of a Health Canada approved COVID-19 vaccine (documentation is required).
D. I am unable to be vaccinated for medical reasons (documentation meeting the criteria of Directive 6/CPSO Guidance is required).
E. I am unable to be vaccinated at this time on human rights grounds (documentation acceptable to WRH is required).

Please upload your 1st dose QR Code (Ontario) / Receipt:

Delete Current File

Date of 1st dose:

Please upload your 2nd dose QR Code (Ontario) / Receipt:

Delete Current File

Date of 2nd dose:

Please upload your 3rd dose QR Code (Ontario) / Receipt:

Delete Current File

Date of 3rd dose:

Please upload medical documentation as stated in Directive 6 or CPSO guidance.:

Delete Current File

Please indicate the protected ground under the Human Rights Code: