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New York State COVID-19 Vaccine Form

Patient Information

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 of an age and, if applicable, immunocompromised (e.g., moderate to severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments) or a member of a certain population who received the Pfizer vaccine series at least 6 months ago (e.g., 65 years or older, a resident of a long term care facility, 50-64 years with an underlying medical condition, 18-49 years with an underlying medical condition based on individual benefits and risks, 18-64 years and at an increased risk for COVID-19 exposure and transmission because of occupational or institutional setting based on individual benefits and risks) as authorized by an Emergency Use Authorization to receive this vaccine, or, the person for whom I am legally authorized to make health care decisions is of an age and, if applicable, immunocompromised or a member of a certain population who received the Pfizer vaccine series at least 6 months ago as authorized by an Emergency Use Authorization to receive this vaccine. 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
This question requires a valid date format of MM/DD/YYYY.
calendar MM/DD/YYYY
This question requires a valid number format.
(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 these settings do you primarily work in? *This question is required.
Which of these settings do you primarily work in? *This question is required.
Which of these settings do you primarily work in? *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. What is your gender identity? *This question is required.
9. What is your sexual orientation? *This question is required.
This question requires a valid date format of MM/DD/YYYY.
calendar
11. Would you like a confirmation via email? *This question is required.
This question requires a valid email address.