• COVID-19 Vaccination Eligibility Certification Form

  • Format: (000) 000-0000.
  • Date Today
     - -
  • P1A1: Are you immunocompromised or do you have a high risk condition (i.e. cancer, chronic kidney disease, chronic obstructive pulmonary disease (COPD), down syndrome, heart condition, obesity, pregnant, sickle cell disease, smoker, type 2 diabetes mellitus)?
  • P1A1: Do you live in an assisted living facilities or similar settings for older or medically vulnerable individuals Long-term care settings?
  • P1A1: Do you work in a hospital: Acute care, Psychiatric and correctional facility hospitals, Skilled nursing facilities, Paramedics, EMTs and others providing emergency medical services, including Dialysis Centers?
  • P1A2: Do you live in an Intermediate care facility for persons who need non-continuous nursing supervision and care or in a Home health care facility?
  • P1A2: Do you work in an Intermediate care facility, primary care clinic, health center, correctional facility clinic, urgent care clinic, or working as or working as a public health field staff or a community health worker?
  • P1A3: Do you work in a laboratory, pharmacy, veterinary clinic, dental and other oral health clinics?
  • P1A3: Do you work in a specialty clinic (i.e. cardiology, neurology, optometry, outpatient, surgery, physical therapy, etc.), or other health testing centers?
  • P1B1: Do you work as a Frontline Essential Worker under Education, Childcare Emergency Services, Food and Agriculture sector?
  • P1B2: Do you work under transportation and logistics, industrial, commercial, residential, and sheltering facilities and services?
  • P1B2: Do you work under critical manufacturing, congregate settings with outbreak risk sector such as for the incarcerated or the homeless?
  • P1C: Do you work in a sector under energy, water and waste water, chemical and hazardous materials, finance services, IT and communication, government operations / community-based essential functions, defense sector?
  • P1C: Do you work under the sector of the government or under community-based essential functions, energy or defense?
  • Date of Birth
     - -

  • Thank you for the information you have provided. Based on your answers, you are eligible for {finalTier} under the COVID-19 Vaccination Distribution Plan.

    For vaccine eligibility, you will need to provide us with all the information requested in this form (name, address, phone, email). You will be contacted by our representative once the vaccine is available for you to receive. 

    Please note that the information collected in this form is solely used for the purpose of COVID-19 vaccination efforts and to determine the eligibility of the vaccine plan administration. We will never sell or share your information to any third party.

  • Thank you for the information you have provided. Based on your answers, you will be eligible for COVID-19 vaccine once it is offered to all people your age who do not have high-risk health conditions.

    For vaccine eligibility, you will need to provide us with all the information requested in this form (name, address, phone, email). You will be contacted by our representative once the vaccine is available for you to receive. 

    Please note that the information collected in this form is solely used for the purpose of COVID-19 vaccination efforts and to determine the eligibility of the vaccine plan administration. We will never sell or share your information to any third party.

  • Thank you for the information you have provided. Currently, there is no approved COVID-19 vaccine for children.

    For notification for updates about vaccine eligibility, you will need to provide us with all the information requested in this form (name, address, phone, email). You will be contacted by our representative once the vaccine is available for you to receive. 

    Please note that the information collected in this form is solely used for the purpose of COVID-19 vaccination efforts and to determine the eligibility of the vaccine plan administration. We will never sell or share your information to any third party.

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