Vaccine Education Video Attestation Form

Important

Before completing this form, please carefully review the following:

• This form is for conscience and religious exemptions only. If you have a medical exemption, please have your health care provider complete the statement of medical exemption form.
• This exemption is for a child that lives in Durham Region or attends a school in Durham Region.
• If your child does not live or attend a school in Durham Region, please use the public health unit locator tool to find your correct public health unit.
• I am providing a non-medical exemption for a child to whom I am the parent/legal guardian.

Please review the notice of collection and consent of information below to continue

COLLECTION OF PERSONAL AND PERSONAL HEALTH INFORMATION

We collect, use, and release your personal and personal health information under the authority of the Health Protection and Promotion Act R.S.O. 1990 c.H.7, s.5, and the Immunization of School Pupils Act (ISPA), R.S.O. 1990, s. 11(1) and its Regulations. This information is collected for the purpose of assessing, keeping records, and reporting on the immunization status and exemptions of children going to schools in the province of Ontario. Information collected is maintained electronically in a provincial immunization information system that is provided by the Ontario Ministry of Health. Information will be collected, used, and disclosed in accordance with the Personal Health Information Protection Act, 2004, S.O. 2004, c. 3. Questions about this collection of information should be addressed to the Durham Region Health Department, Manager, Health Information, Privacy and Security at 605 Rossland Rd E., P.O. Box 730, ON, L1N 0B2, (905) 668-7711.

CONSENT TO THE COLLECTION OF INFORMATION
I consent to the Medical Officer of Health for the Regional Municipality of Durham electronically collecting the personal and personal health information I submit through this online form for the following purposes:

1. To confirm my completion of watching the vaccine education video and to create my client record in order to issue me an Education Session Certificate.
2. To keep an electronic record of immunization or immunization exemptions for a student as required by ISPA (if relevant), and
3. To support any programs/services administered by any public health unit in Ontario related to preventing the spread of disease and/or the promotion and protection of the health of others in Ontario.

I acknowledge that I am providing immunization exemption information about a student as required by law. I agree to provide the information for the purposes listed above.

We will contact you for the purposes of providing you with your Education Certificate and/or to request clarification or follow-up regarding the information submitted.