DBIS Student Vaccination Form
Student Number
Please enter the Student's School Code (S5xxxxx)
Student Name
Please choose one:
*
Has received 1st, 2nd and 3rd dose of COVID-19 vaccine
Has received 1st dose and 2nd dose of COVID-19 vaccine
Has received 1st dose of COVID-19 vaccine only
Planning or booked to receive 1st dose of COVID-19 vaccine
Not planning to receive COVID-19 vaccine
Declared medically unsuitable to receive COVID-19 vaccine
Please attach Medical Exemption Certificate
*
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Cancel
of
Vaccine Name
*
Sinovac (CoronaVac)
BioNTech Comirnaty (Pfizer or Fosun)
AstraZeneca Oxford
Other
Date of Third Vaccination
*
/
Day
/
Month
Year
Date
Date of Second Vaccination
*
/
Day
/
Month
Year
Date
Date of First Vaccination
*
/
Day
/
Month
Year
Date
Please attach the COVID-19 Vaccination Record
*
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of
Has had COVID-19 infection
*
Yes
No
Please attach the COVID-19 Positive Doctor's Certificate
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of
Has temporary vaccine pass (recent arrival)?
*
Yes
No
Please attach the Temporary Exemption Certificate
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Cancel
of
Comments
Date:
*
-
Day
-
Month
Year
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