Report of COVID-19 Vaccination Status
We are asking all students, faculty and staff to submit a “Report of COVID-19 Vaccination Status” form when they are vaccinated for COVID-19, or receive a booster shot. This information will inform our decisions regarding protocols for keeping the Merion Mercy community healthy and safe. It is also necessary for performing contact tracing should that be needed.
Parents can submit on behalf of students, or students may submit for themselves, but please only submit one form for each student.
In addition, please upload a copy of the COVID-19 vaccination card that has the dates and type of vaccine listed on it into the student's immuniation record on Magnus Health.
Thank you for your understanding and cooperation.
Director of Operations
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Student First Name
Student Last Name
Year of Graduation
Have you been vaccinated for COVID-19?
If vaccinated, type of vaccine:
Pfizer (2 shots)
Moderna (2 shots)
Johnson & Johnson (one shot)
If vaccinated when was your first shot?
If vaccinated when was your second shot (for Moderna and Pfizer)?
If you received a booster shot please indicate the type you received:
Johson & Johnson
If you received a booster shot please indicate the date received:
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This form was created inside of Merion Mercy Academy.