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I hereby certify under penalty of law that I myself am, or the person for whom I am legally authorized to make health care decisions, fall into one of the following categories:
- 5 years of age or older and in the process of completing my initial Pfizer COVID-19 vaccine series; OR
- 12 years of age or older, immunocompromised (e.g., moderate to severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments) and received a completed COVID-19 vaccine series at least 28 days ago; OR
- 18 years of age or older and either: in the process of completing my initial Janssen (J&J) or Moderna COVID-19 vaccine series, or received a WHO-authorized COVID-19 vaccine and require a dose of Pfizer or Moderna COVID-19 vaccine to complete my vaccine series, or received a completed WHO authorized vaccine series at least 5 months ago and require a booster dose; OR
- 12 years of age or older and either received the Pfizer vaccine at least 5 months ago or received an initial booster dose at least 4 months ago and immunocompromised (e.g., moderate to severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments); OR
- 18 years of age or older and received either the Moderna vaccine series at least 5 months ago, the Janssen/J&J vaccine at least 2 months ago, or the Janssen/J&J vaccine as both a primary series and an initial booster dose at least 4 months ago; OR
- 50 years or older and received an initial booster dose at least 4 months ago.
and therefore authorized by an Emergency Use Authorization or Emergency Use Instructions 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.
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.
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