Communicable disease assessment intake form

I am a physician employed by Covenant Health

I am a physician employed by Alberta Health Services

I am not a physician

Please refer to Alberta Health Services' processes for communicable disease assessments.

First name

Last name

Personal healthcare number

Province where your personal healthcare number was issued

Date of birth

Main phone number

Alternate phone number

By providing this information, you consent to Occupational Health, Safety and Wellness contacting you at this email address. Please make sure your email address is entered correctly.

Street address

City

Province/Territory

Postal code

Job title

Include volunteer or physician, etc.

Department

Site

Manager or volunteer coordinator

Start date

Vaccination record

Please upload all of your immunization records as a single file, including any applicable titer testing history (laboratory testing to verify immunity). Vaccination records must contain two personal identifiers, such as legal name and date of birth.

If you would rather not upload at this time, please email your records to occhealthnurse@covenanthealth.ca.

One file only.
10 MB limit.
Allowed types: jpg, jpeg, pdf.

Choose file

Is there anything else you would like to share about your immunization history? If you do not have vaccination records, please indicate below.

Collection of personal information – notification statement:
The personal information requested on this form is collected under the authority of Section 4(c) of the Alberta Protection of Privacy Act (POPA) and will only be used for the purpose of tracking, follow up and communications regarding your request. For information about the collection and use of this information, contact the Covenant Health Information and Privacy Office at One Twelve Campus, 10130 112 Street NW, Edmonton, AB, T5K 2K4, Tel. 1.866.254.8181.