Certification of Membership in Priority Vaccination Group

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, I hereby certify under penalty of law that:

1. I qualify in one of the following capacities that is eligible for vaccine, at this time or by the dates indicated:
   • 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 and OASAS, and residents in congregate living situations, run by the OPWDD, OMH, 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 there of 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 Outpatient/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.

OR


2. With respect to residents of residential programs or patients of hospitals certified or operated by the NYS Office of Mental Health (OMH) or Office for People With Developmental Disabilities (OPWDD), the person for whom this certification is submitted on behalf of is a resident or patient of such residential program or hospital.

IMPORTANT INFO FOR VACCINE VISITS

We look forward to seeing you for a Moderna COVID-19 vaccine visit. Per CDC and DOH requirements, we are only able to vaccinate NY frontline healthcare workers with a healthcare ID badge at this time.

Please do not save a spot if any of the following CDC contraindications apply, as we will not be able to administer a vaccine during your visit:

• Current illness
• COVID diagnosis or illness in the last 90 days
• COVID antibody treatment in the last 90 days
• Any vaccination in the last 14 days, including the flu shot
• Prior Pfizer COVID-19 vaccine
• First Moderna COVID-19 vaccine less than 28 days ago
• Severe allergic reaction to a prior COVID-19 vaccine or its components such as polyethylene glycol