New York State COVID-19 Vaccine Form

This form cannot be used to schedule an appointment. Complete this form only once you have a scheduled appointment.

I hereby certify under penalty of law that I am eligible to receive COVID-19 vaccine, or the person for whom I am legally authorized to make health care decisions for is eligible to receive COVID-19 vaccine, because:

1. I am a resident of New York State (or the person for whom I am legally authorized to make health care decisions is a resident of New York State).

2. I perform work in New York (or the person for whom I am legally authorized to make health care decisions performs work in New York State).

3. I study in New York State.

I understand that I will have to supply proof of eligibility. I agree that by typing my name below, I am hereby affixing my electronic signature as if I had physically signed this certification.

1. Patient Information

First Name *This question is required.

Last Name *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar MM/DD/YYYY

Zip Code *This question is required. This question requires a valid number format.

County *This question is required.

Phone Number *This question is required.

(XXX) XXX - XXXX

The New York State Department of Health is requesting the information below in order to deliver the most effective Statewide vaccination program. By filling out this form, you are enhancing the State’s response to the COVID-19 pandemic. The information you provide will be protected pursuant to the New York State Personal Privacy Protection Act and any other applicable state or federal law.

2. Which of the following best describes your ethnic group? *This question is required.

3. Which of the following best describes your race? Please select all that apply. *This question is required.

4. Do you have a comorbidity or underlying condition as defined by the New York Department of Health? *This question is required.
For a list of comorbidities, visit: https://www.ny.gov/sites/ny.gov/files/atoms/files/ComordbititiesCOVID19.pdf

5. Are you a public-facing essential worker? *This question is required.

Which of the following best describes your job? *This question is required.

Which of these settings do you primarily work in? *This question is required.

Which of the following best describes your primary role?

6. Are you currently living in a congregate setting? *This question is required.

Which of these settings do you live in? *This question is required.

7. Do you study in New York State? *This question is required.

8. Date of first scheduled appointment *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

9. Would you like a confirmation via email? *This question is required.

Email Address *This question is required. This question requires a valid email address.