Student Vaccination - Confidential Report

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In order for Cardinal Newman High School to manage the required contact tracing and exposure mandates, the school's Safety Director/Contact Tracer (Mr. John Gilson) needs to know the vaccination status of every student and employee. Your answers are confidential and will be kept private.

Please answer the following questions using only the responses that are given. Please DO NOT send any medical information, provide any other answers, or elaborate in any way.

Those who do not wish to respond to this request will be considered unvaccinated. Thank you for your partnership and cooperation.

Please submit one form per child. Once again, your answers are confidential and will be kept private.

With regards, Principal Nicholas Reynolds

Grade of Student *

9th

10th

11th

12th

Last Name of Student *

First Name of Student *

Current Vaccination Status *

Unvaccinated

Partially Vaccinated

Fully Vaccinated

Please provide only the dates of your vaccination: (Write "none" if unvaccinated) *

Name of parent or guardian who submitted this form: *

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