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New York State COVID-19 Vaccine Form

Your Information

Certification of Membership in Priority Vaccination Group

I understand that vaccine supply is currently limited and, therefore, subject to strict prioritization in accordance with Centers for Disease Control and New York State Department of Health directives. With that understanding, and with the understanding that I will have to supply proof of my eligibility, I hereby certify under penalty of law that I belong to one of the below priority groups eligible for vaccination:

1. I am age 65 or older and I reside in New York State.


- OR -

2. I am currently employed by a New York employer, or am otherwise eligible in New
York based on work, paid or unpaid, in New York, in one of the following categories,
and am either required to have in-person contact with members of the public or with coworkers, or I am unable to work remotely:

  • First Responder or Support Staff for First Responder Agency
    • Fire
      • State Fire Service, including firefighters and investigators (professional and volunteer)
      • Local Fire Service, including firefighters and investigators (professional and volunteer)
    • Police and Investigations
      • State Police, including Troopers
      • State Park Police, DEC Police, Forest Rangers
      • SUNY Police
      • Sheriffs' Offices
      • County Police Departments and Police Districts
      • City, Town, and Village Police Departments
      • Transit of other Public Authority Police Departments
      • State Field Investigations, including DMV, SCOC, Justice Center, DFS, IG, Tax, OCFS, SLA
    • Public Safety Communications
      • Emergency Communication and PSAP Personnel, including dispatchers and technicians
    • Other Sworn and Civilian Personnel
      • Court Officer
      • Other Police or Peace Officer
      • Support or Civilian Staff for Any of the Above Services, Agencies, or Facilities
  • Corrections
    • State DOCCS Personnel, including correction and parole officers
    • Local Correctional Facilities, including correction officers
    • Local Probation Departments, including probation officers
    • State Juvenile Detention and Rehabilitation Facilities
    • Local Juvenile Detention and Rehabilitation Facilities
  • P-12 Schools
    • P-12 school (public or non-public) or school district faculty or staff (includes all teachers, substitute teachers, student teachers, school administrators, paraprofessional staff, and support staff including bus drivers)
    • Contractor working in a P-12 school or school district (including contracted bus drivers)
    • Licensed, registered, approved or legally exempt group childcare
  • In-person college faculty and instructors
  • Employees or Support Staff of licensed, registered, approved or legally exempt group Childcare Setting
  • Licensed, registered, approved or legally exempt group Childcare Provider
  • Public Transit
    • Airline and airport employee
    • Passenger railroad employee
    • Subway and mass transit employee (i.e., MTA, LIRR, Metro North, NYC Transit, Upstate transit)
    • Ferry employee
    • Port Authority employee
    • Public bus employee
  • Public facing grocery store workers
  • Individual living in a homeless shelter where sleeping, bathing or eating accommodations must be shared with individuals and families who are not part of your household
  • Individual working (paid or unpaid) in a homeless shelter where sleeping, bathing or eating accommodations must be shared by individuals and families who are not part of the same household, in a position where there is potential for interaction with shelter residents
  • High-risk hospital and FQHC staff, including OMH psychiatric centers.
  • Health care or other high-risk essential staff who come into contact with residents/patients working in LTCFs and long-term, congregate settings overseen by OPWDD, OMH, OCFS, OTDA and OASAS, and residents in congregate living situations, overseen or funded by the OPWDD, OMH, OCFS, OTDA and OASAS.
  • Certified NYS EMS provider, including but not limited to Certified First Responder, Emergency Medical Technician, Advanced Emergency Medical Technician, Emergency Medical Technician – Critical Care, Paramedic, Ambulance Emergency Vehicle Operator, or Non-Certified Ambulance Assistant.
  • County Coroner or Medical Examiner, or employer or contractor thereof who is exposed to infectious material or bodily fluids.
  • Licensed funeral director, or owner, operator, employee, or contractor of a funeral firm licensed and registered in New York State, who is exposed to infectious material or bodily fluids.
  • Staff of urgent care provider.
  • Staff who administer COVID-19 vaccine.
  • All Outpatient/Ambulatory front-line, high-risk health care workers of any age who provide direct in-person patient care, or other staff in a position in which they have direct contact with patients (i.e., intake staff).
  • All front-line, high-risk public health workers who have direct contact with patients, including those conducting COVID-19 tests, handling COVID-19 specimens and COVID-19 vaccinations.
  • Home care workers and aides, hospice workers, personal care aides, and consumer-directed personal care workers.
  • Staff and residents of nursing homes, skilled nursing facilities, and adult care facilities.

3. The person for whom I am submitting this certification is a resident or patient of one
of the following:
  • Nursing home regulated by the NYS Department of Health (DOH)
  • Residential program or hospital certified or operated by the NYS Office of Mental Health (OMH), Office for People With Developmental Disabilities (OPWDD), Office of Children and Family Services (OCFS) or Office of Addiction Services and Supports (OASAS).
I have read the list of vaccination priority groups above. I hereby certify under penalty of
law that I am member of a priority group eligible for vaccination. I agree that by typing
my name below, I am hereby affixing my electronic signature as if I had physically
signed this certification.
1. Your Information
This question requires a valid date format of MM/DD/YYYY.
calendar MM/DD/YYYY
This question requires a valid number format.
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. Are you a worker in a patient-facing healthcare setting or a congregate living setting? *This question is required.
Which of these settings do you primarily work in? *This question is required.
5. Are you a First Responder or Support Staff for First Responder Agency? *This question is required.
Which of these settings do you primarily work in? *This question is required.
6. Are you employed by a Corrections Agency? *This question is required.
Which of these settings do you primarily work in? *This question is required.
7. Are you employed in a P-12 school or school district? *This question is required.
Which of these settings do you primarily work in? *This question is required.
8. Are you an employee or support staff in a licensed, registered, approved, or legally exempt group childcare setting? *This question is required.
9. Are you a licensed, registered, approved, or legally exempt group childcare provider? *This question is required.
10.

Are you a public-facing grocery store worker?

*This question is required.
11.

Are you an in-person college faculty or instructor?

*This question is required.
12. Are you a Public Transit employee? *This question is required.
Which of these settings do you primarily work in? *This question is required.
13. Are you employed as a coroner, medical examiner, or in funeral services? *This question is required.
Which of the following best describes your primary role?
14. Are you currently living in a congregate setting? *This question is required.
Which of these settings do you live in? *This question is required.
15. Are you a State Employee, Local government employee, or Employee of a Public Authority? *This question is required.
This question requires a valid date format of MM/DD/YYYY.
calendar
17. Would you like a confirmation via email? *This question is required.
This question requires a valid email address.