Menu
Appointments MyChart ER Wait Times
Search
Back

Orlando Health's COVID-19 Vaccine Program - Students & Faculty

Orlando Health's COVID-19 Vaccine Program - Students & Faculty

Orlando Health's COVID-19 Vaccine Program - Students & Faculty

Orlando Health is required to maintain certain COVID-19 vaccine information for individuals during any educational experiences, including but not limited to clinicals, internships, and/or shadowing experiences.

Please provide the following information:

 

Student/Faculty Name: *

Student/Faculty ID:

School Affiliation:

Instructor:

Timeframe of Educational Experience:

Clinical or Non-Clinical *

Please indicate ONE of the two options listed below and complete in its entirety and complete the attestation prior to the first educational experience:

 

Option 1: Document a complete COVID-19 vaccination series. A complete vaccination series is receiving two doses of the Pfizer or Moderna vaccine or the single-dose J&J/Janssen vaccine.

 

  • Date of Dose 1:

    Date of Dose 2:

  • Date of Dose 1:

    Date of Dose 2:

  • Date of Dose 1:

Option 2: Document an exemption from the COVID-19 vaccination.

 

Attestation: *

Legal Guardian First and Last Name (if not self):