COVID-19 Vaccine Declaration Survey


A link will be sent at the above email address for confirmation. You need to click on the link to confirm the email address. If you don't confirm the email address then this application will not be reviewed.

The Region of Waterloo is committed to take every precaution reasonable in the circumstances for the protection of its workers from the exposure of COVID-19. The COVID-19 Vaccine is a key element in the process of ensuring protection of Regional employees against the hazards of COVID-19.

In accordance with the Region of Waterloo’s Mandatory COVID-19 Vaccination Policy, all new employees, volunteers and unpaid students must be fully vaccinated and submit proof against COVID-19 as a condition of hire. Valid medical or Ontario Human Rights Code exemptions may be permitted.
  • A new employee means that a conditional job offer was made as of October 18th, 2021.
  • A new volunteer or unpaid student means that registration into the program was initiated as of October 18th, 2021.
All personal information on this form is collected under the authority of the Occupational Health and Safety Act, Sections 25 (2)(h). This information will only be used for the purposes of complying with the directives in tracking vaccination status and reporting statistical data as required by the Provincial and Federal governments, and any other applicable governing bodies.

If you have any questions about this form or the Vaccination Policy, please email COVIDRecord@regionofwaterloo.ca.

* To submit proof of vaccination, you will need to upload copies of your vaccination receipts. Your receipts can be found on the Ontario COVID-19 Vaccination Portal.

Fully Vaccinated means that you have received:
  • The full series of a COVID-19 vaccine authorized by Health Canada,
  • You received your final dose of the COVID-19 vaccine at least 14 days ago

Proof of Vaccination

Download your enhanced vaccination certificate from Ontario COVID-19 Vaccination Portal and upload it below with the number and date of the most recent dose you received.

Highest Vaccine Dose
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