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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 are at least 18 years or older and received the Janssen (J&J) vaccine at least 2 months ago, or are at least 16 years or older and received the Pfizer vaccine at least 6 months ago, or are at least 18 years or older and received the Moderna vaccine series at least 6 months ago as authorized by an Emergency Use Authorization or Emergency Use Instructions 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 are at least 18 years or older and received the Janssen (J&J) vaccine at least 2 months ago or at least 16 years or older and received the Pfizer vaccine at least 6 months ago or at least 18 years or older and received the Moderna vaccine series at least 6 months ago as 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.
 

1. Patient Information
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.
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11. Would you like a confirmation via email? *This question is required.
This question requires a valid email address.
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