Vaccination Record Request

First name*

Last name*

I am up to date on my seasonal influenza vaccination*

Yes

I am up to date with my COVID vaccination/booster*

Yes

Please upload proof of current vaccination

Declinations (Select all that apply)

I have not recevied any COVID vaccinations AND I decline to receive one

I HAVE received a previous COVID vaccine, but I decleien to receive the booster.

I decline the annual influenza vaccine

I am not providing my vaccination status

Affirmations (Please select all)*

I understand that by declining an updated vaccine that I am responsible for knowing the mask policy AND the overall policies for my employment (if applicable).

I understand that Action Ambulance (as part of their DPH/OEMS reporting requirements) will be submitting the information to the Massachusetts Department of Public Health as statistical information & none of your HPI will be reported.

I understand that during an Office of Emergency Medical Services inspection of Action Ambulance records that we may have to provide samples of records obtained. No further information will be shared with OEMS.

I understand that any deliberate or intentional misrepresentation or falsification if information provided, I may be held to progressive discipline, up to and including termination

By signing below, I acknowledge the accuracy & truthfulness of the answer provided to this questionnaire. *

The Massachusetts Department of Health & The Office of Emergency Medical Services requirement for ambulance services to collect seasonal influenza & COVID vaccination/booster records survey. Per updated Administrative Requirements, Massachusetts licensed ambulances services are required to collect and submit seasonal influenza & COVID vaccination status of it's providers.

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1 Jewel Drive, Building #3, Wilmington MA, 01887

Tel: (978) 253-2664

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