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 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 thatI

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 30 or older and I reside in New York State.

2. I am a resident of New York and currently perform work in one of the below categories, either paid or unpaid, or I am a non-resident but perform such work in New York; and I 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

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

New York State COVID-19 Vaccine Form

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,

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

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 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 essential in-person staff 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

New York State COVID-19 Vaccine Form

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 Dutpatient/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. Restaurant workers, including workers in permitted soup kitchen and congregate meal programs Restaurant delivery workers Public facing hotel workers For-hire vehicle drivers Public-facing government and public employees Not-for-profit workers who provide public-facing services to New Yorkers in need Essential in-person public-facing building service workers and providers of essential building services

New York State COVID-19 Vaccine Form

Cancer (current or in remission, including 9/11-related cancers) Chronic kidney disease Pulmonary Disease, including but not limited to, COPD (chronic obstructive pulmonary disease), asthma (moderate-to-severe) pulmonary fibrosis, cystic fibrosis, and 9/11 related pulmonary diseases Intellectual and Developmental Disabilities including Down Syndrome Heart conditions, including but not limited to heart failure, coronary artery disease, cardiomyopathies, or hypertension (high blood pressure) Immunocompromised state (weakened immune system) including but not limited to solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, use of other immune weakening medicines, or other causes Severe Obesity (BMI 40 kg/m2), Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2) Pregnancy Sickle cell disease or Thalassemia Type 1 or 2 diabetes mellitus Cerebrovascular disease (affects blood vessels and blood supply to the brain) Neurologic conditions including but not limited to Alzheimer's Disease or dementia Liver disease

4. 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 a 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.

New York State COVID-19 Vaccine Form

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.

Do you have a comorbidity or underlying condition as defined by the New York Department of

New York State COVID-19 Vaccine Form