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 Hospital, Long-Term Care, and Retirement Home staff who have completed their training.

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