"*" indicates required fields Información del estudianteNombre / Name* Nombre/Name Apellidos/Last Names Id de estudiante / Student Id* Teléfono / Phone Number*Recinto / Campus*Seleccione RecintoAguadillaAreciboBarranquitasBayamónFajardoGuayamaMetroPonceSan GermánEscuela de OptometríaFacultad de DerechoCorreo electrónico asignado por universidad / Email assigned by university* Correo electrónico personal / Personal email Información de Vacuna / Vaccine InformationEn cumplimiento con la Orden Administrativa del Departamento de Salud del Gobierno de Puerto Rico (OA-2022-533), según enmendada, todo estudiante de una institución educativa debe haber recibido las primeras dos dosis de la vacuna contra el COVID-19, para participar de cualquier actividad presencial en la institución. In compliance with the Administrative Order from the Department of Health of the Government of Puerto Rico (OA-2022-533), as amended, every student of an educational institution must have received the first two doses of the COVID-19 vaccine, in order to participate in any face-to-face activity at the institution.¿Tienes la tercera dosis de refuerzo de la vacuna contra el COVID-19? / Do you have the third dose (booster) of the COVID-19 vaccine?*SeleccioneSíNoTipo de vacuna/ Vaccine type*SeleccionePfizerModernaOtra-OtherFecha del refuerzo mm/dd/yyyy*Mes123456789101112Día12345678910111213141516171819202122232425262728293031Año202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920¿Tiene las primeras dos dosis de la vacuna contra el COVID-19? / Have you received the first two doses of the COVID-19 vaccine?*SeleccioneSíNoTipo de Vacuna/ Vaccine type*Seleccione/SelectModernaPfizerJohnson & JohnsonOXFORD/ASTRAZENECASERUM INSTITUTE OF INDIA: COVISHIELDSINOPHARM (BEIJING): BBIBP-CorVSINOVAC: CORONAVACLo sentimos, no puede continuar con los siguientes pasos. Para completar el formulario tiene que haber recibido las primeras dos dosis de la vacuna contra el COVID- 19. Una vez esté vacunado, podrá acceder nuevamente al formulario para continuar con el trámite correspondiente. Para mayor información, comuníquese con el Decanato de Estudiantes de su recinto. We are sorry, you cannot continue with the next steps. To complete the form, you must have received the first two doses of the COVID-19 vaccine. Once you are fully vaccinated, you can access the form again to continue with the corresponding process. For more information, contact the Dean of Students of your campus.Fecha de última dosis/ Last dose date mm/dd/yyyy*Mes123456789101112Día12345678910111213141516171819202122232425262728293031Año202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Frontal de la evidencia de vacunación/ Front side of the vaccination evidence.*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Parte Posterior de la evidencia de vacunación/ Back side of the vaccination evidence*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Identificación con Foto/ Photo Id*To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your file Maximum: 1 file(s)Maximum size: 8 MB File Download Consentimiento/Consent* Acepto/AcceptUna vez completado este paso, deberá certificar que la información provista es cierta y que, de presentar información falsa relacionada con la administración de la vacuna contra el COVID-19, estará sujeto a la imposición de sanciones disciplinarias conforme dispone el Reglamento General de Estudiantes vigente. Once this step is completed, you must certify that the information provided is true and that, if you present false information related to the administration of the COVID-19 vaccine, you will be subject to the imposition of disciplinary sanctions in accordance with the current General Student Regulations.EmailThis field is for validation purposes and should be left unchanged.
