COVID-19 Vaccine/Immunity Disclosure Form
Legal First Name
First Name is required
Legal Middle Initial (if applicable)
Legal Last Name
Last Name is required
Date of Birth
Date of Birth is required
Employee Number
Work Site
Wataynikaneyap (Watay)
Ontario East West Tie Line (OEWTL)
Toronto and area operations (not Watay or OEWTL)
NFLD (Nalcor project)
Manitoba
Alberta
Saskatchewan
BC
US Operations
Other:
Edmonton Business office and area operations
Calgary Head office and area operations
Leduc office and area operations
Grand Prairie and area operations
Full time in office
Field work in ON area
Full time in office
Field work in MB area
Work Site is required
Vaccine Dose # 1
Pfizer
Moderna
AstraZeneca
Janssen Vaccine (Johnson & Johnson) -- Only 1 dose required
Other
Date of COVID-19 Vaccination (first dose)
Vaccine Dose # 2
Not Applicable
Pfizer
Moderna
AstraZeneca
Other
Date of COVID-19 Vaccination (second dose)
If your 2nd vaccine shot is not completed, do you plan to get your second vaccination shot?
Yes
No
N/A
If yes, when do you plan on getting your second vaccination shot?
Has your 2nd vaccination shot been officially booked with a health unit?
Yes
No
N/A
Do you have a copy of your COVID-19 vaccine records?
Yes
No
If you have a copy of your vaccine records (attach file(s)):
Please note, if COVID-19 vaccine records are not submitted, Valard may request proof of your vaccine records at a later date.
Were you ever diagnosed by public health as having COVID-19?
Yes
No
If yes, provide date (month and year)
If you were diagnosed with COVID-19 more than once, please list any additional dates below
Affirmation
Yes, I certify that the information provided on this form is correct, complete and truthful. I understand that providing false information could negatively impact Valard’s operations and the safety of other Valard employees, their families, and the safety of communities we work in.
No. By clicking “No” this form will be cancelled, and no information will be submitted to Valard. To be clear, by clicking “NO”, Valard will not receive ANY information on this form, the form will be cleared / erased of all entered dataand the form will be completely reset with ZERO data saved.
CLEAR
Signature
In lieu of a signature, I certify that the information entered is correct