COVID-19 Vaccine Distribution Program Training Attestation

Thank you for completing all of the training requirements for the COVID-19 Vaccine Distribution Program. This form is for primary care providers and staff who have completed their training. Note: this attestation is not meant for Hospital staff.

Please complete the short survey below to attest to the training.

Additional information is collected on this survey for registering you as a user in COVaxON.

*Last Name:

*First Name:

*Name of Organization:

*What role will you have in COVaxON?
COVax Site Staff: Includes tasks such as Client Check-In and Check-Out
COVax Vaccinator: May include support staff who are tasked with Client Check-In, Dose Administration, and Client Check-Out
COVax Site Super User: 1 minimum, 2 recommended per organization. Includes all functionality in COVax.

COVax Site Staff

COVax Vaccinator

COVax Site Super User

*Work Email Address:
It is recommended that an organization email is used to create a COVax account, due to enhanced security, however personal emails can be used if needed.

Confirm email address

*Do you have an existing COVax User account?

No, I do not have an existing COVax User account

Yes, I have an existing COVax User account.

Work Phone Number:
Please enter as 5194563504

Mobile Phone Number:
Please enter as 5194563504

*I have completed a review of ALL of the following training content:

Training Overview Document

COVax Acceptable Use Policy

Vaccine Cyber Security Document