Health and Seniors Care

COVID-19 Immunization and Test Record Request

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COVID-19 Immunization and Test Record Request

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To apply for a Manitoba Digital Immunization Card (or the physical card), please visit: https://immunizationcard.manitoba.ca.

Digital immunization cards, which shows a QR code, as proof of immunization for non-health care services such as travel, access to visitation at personal care homes and hospitals, access to sports and entertainment venues, restaurants, bars and lounges, other businesses as required by the business, or non-Manitoba immunization cards. A copy of your immunization record is NOT required to access these services.

Have you attempted to report this error using the COVID-19 Immunization and Test Record Request form? Yes No

Please do not submit an additional form for the same error. Your previous request is being addressed.

Please complete ALL of the information listed below. Each individual needs to complete their own separate request.

If you are requesting that your immunization record be updated, please include a digital copy of your record as well as official government photo ID.

Note:

A digital record from your vaccine provider must include official identification and a valid QR code. Official photo ID may be either a driver's license, passport, government issued identification or Canadian Armed Forces ID.
All submitted documents must be .jpg or .jpeg files and can be no larger than 3MB each in size.

Request

Please provide the following information:

Name (Must match Passport and/or Health Card name exactly)

Date of Birth

PHIN

I do not have a PHIN

Phone Number

Email Address

Mailing Address

Address

City

Province

Postal Code

Physician Contact Information Name of physician Physician's phone number Address of Physician's Office

All documents submitted must be .jpg or .jpeg files and no larger than 3MB each in size.

COVID-19 Dose Records

This information is needed to be able to process requests.

Which dose is this for?

Area where you received your vaccine

Location

I do not recall the location

Date

I do not recall the date

Dose Record

COVID-19 Vaccine Dose Record 2

Which dose is this for?

Area where you received your vaccine

Location

I do not recall the location

Date

I do not recall the date

Dose Record

COVID-19 Vaccine Dose Record 3

Note: Only three records can be submitted at one time. If you need to submit a fourth dose record, please fill out the form again with only forth dose information.

Which dose is this for?

Area where you received your vaccine

Location

I do not recall the location

Date

I do not recall the date

Dose Record

Vaccine Information

This information is needed to be able to process requests.

Vaccine

Area where you received your vaccine

Location

I do not recall the location

Date

I do not recall the date

Proof of Vaccination

All documents submitted must be .jpg or .jpeg files and no larger than 3MB each in size.

Upload Proof of Vaccination Which dose is this for?

Upload Proof of Vaccination

Which dose is this for?

Upload Proof of Vaccination

Which dose is this for?

Note: Only three records can be submitted at one time. If you need to submit a fourth dose record, please fill out the form again with only forth dose information.

Additional Documents

All documents submitted must be .jpg or .jpeg files and no larger than 3MB each in size.

Upload Additional Documentation

Privacy Notice and Consent

IMMUNIZATION RECORD UPDATE REQUEST
PRIVACY NOTICE AND CONSENT FOR DISCLOSURE OF
PERSONAL INFORMATION AND PERSONAL HEALTH INFORMATION

In order for the Government of Manitoba's Department of Health and Seniors Care ("MHSC") to process your update request and to make any updates to your immunization record (including updating that you received a vaccination from outside of the jurisdiction), personal information and personal health information about you will be collected and must be disclosed to third parties. Please see below for more details.

COLLECTION OF YOUR PERSONAL INFORMATION AND PERSONAL HEALTH INFORMATION

MHSC is collecting the following personal information and personal health information for the purposes of making updates to your immunization record (including verifying your identity and conducting any investigations required to process your update request) and for contacting you to provide the status of your update request:

your full name;
your date of birth;
your personal health identification number (PHIN);
when and where you received your COVID-19 vaccine immunization, if applicable;
record of immunization from the jurisdiction you received your vaccine (if received outside Manitoba), if applicable;
your phone number; and
your home address.

MHSC is authorized to collect your personal information under:

subsection 36(1)(b) of The Freedom of Information and Protection of Privacy Act, C.C.S.M. c. F175 ("FIPPA"); and
subsection 13(1) of The Personal Health Information Act, C.C.S.M. c. P33.5 ("PHIA");

because collecting the information relates directly to and is necessary for MHSC to verify your identity, conduct any investigations required to process your update request, update your information on your immunization record, and contact you with the status of your update request. MHSC will only collect as much personal information and personal health information as is necessary.

Your phone number and/or home address will be used to contact you in order to provide you with the status of your update request.

DISCLOSURE OF YOUR PERSONAL INFORMATION AND PERSONAL HEALTH INFORMATION

MHSC will need to disclose your personal information and personal health information to one or more of the following entities:

Shared Health Inc.;
applicable Regional Health Authority:
- Winnipeg Regional Health Authority;
- Interlake-Eastern Regional Health Authority;
- Southern Health-Santé Sud Regional Health Authority;
- Prairie Mountain Regional Health Authority;
- Northern Regional Health Authority.
For members of the Canadian Armed Forces
- Canadian Forces 23 Health Services Centre Winnipeg;
- Canadian Forces 11 Health Services Centre Shilo.

for the purposes of conducting any investigations required to process your update request and to update your information on your immunization record.

In order for MHSC to process your update request, you will be required to consent to MHSC disclosing your personal information and personal health information to the entities as described above.

MHSC will have the authority to disclose your personal information and personal health information for the purposes indicated above under:

section 44(1)(b) of FIPPA; and
section 22(1)(b) of PHIA.

WITHDRAWAL OF YOUR CONSENT

You may withdraw your consent to the further disclosure of the personal information and personal health information provided on this form by contacting:

COVID Immunization Records Information at:
covidimmunizationrecordsinformation@gov.mb.ca

Your consent continues until you notify MHSC that you withdraw your consent. Your consent cannot be withdrawn retroactively.

If you do not provide consent or withdraw your consent prior to completion of your update request, MHSC will not be able to process your update request.

QUESTIONS

Your personal information is protected under FIPPA and your personal health information is protected under PHIA. MHSC, Shared Health and the Regional Health Authorities will only collect, use and disclose as much personal information and personal health information as is necessary and cannot disclose your personal information and personal health information for other purposes, unless it is authorized to do so under FIPPA or PHIA.

For any questions regarding the collection, use or disclosure of your personal information and personal health information, please contact:

Clare Hargrave
Provincial Director, COVID Immunization
4004 - 300 Carlton Street
Winnipeg, MB R3B 3M9
Ph: 204-793-1157
chargrave@sharedhealthmb.ca

YOUR CONSENT TO DISCLOSURE OF YOUR INFORMATION

I consent to Manitoba's Department of Health and Seniors Care disclosing my personal information and personal health information (as described above) to Shared Health Inc. and/or a Regional Health Authority for the purposes of conducting any investigations required to process my update request and to update my immunization record.

Declaration

I declare that all information provided on this form, including the contents of any attachments, is complete and true to the best of my knowledge.

NOTE: Order 28(1) of the COVID-19 prevention orders (signed December 27, 2021) issued under the authority of The Public Health Act states that a person must not copy, modify or alter, or (without authority) create a document or other item that provides, or purports to provide, proof of a person's vaccination status. It is an offence under clause 90(1)(b) of The Public Health Act for a person to fail to comply with an order made under this Act. A person who is guilty of this offence is liable on summary conviction to a fine of not more than $100,000 or imprisonment for a term of not more than one year, or both.

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COVID-19 Immunization and Test Record Request

COVID-19 Immunization and Test Record Request

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Request

Privacy Notice and Consent

IMMUNIZATION RECORD UPDATE REQUEST PRIVACY NOTICE AND CONSENT FOR DISCLOSURE OF PERSONAL INFORMATION AND PERSONAL HEALTH INFORMATION

Declaration

IMMUNIZATION RECORD UPDATE REQUEST
PRIVACY NOTICE AND CONSENT FOR DISCLOSURE OF
PERSONAL INFORMATION AND PERSONAL HEALTH INFORMATION