COVID-19 Janssen Vaccination

New York State Eligibility

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 that I will have to supply proof of my eligibility, I hereby certify under penalty of law that:

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 that I 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:

• Individuals age 18 and older are eligible to be vaccinated with Moderna or Janssen, in addition to all previously eligible groups.
• Individuals age 5 and older are eligible to be vaccinated with Pfizer-BioNTech, in addition to all previously eligible groups.
  

As part of New York’s COVID-19 vaccine administration program, the New York State Department of Health is deploying the New York State COVID-19 Vaccine Form, a form that will request all individuals across New York State to self-report select demographic data such as occupation, race, and ethnicity prior to vaccine administration. This information is critically important for tracking vaccination progress throughout the State and ensuring appropriate vaccine distributions in all regions of the State.

You must fill out the data capture form before administration of the vaccine at Park Chemists. You must show your email confirmation from New York State to Park Chemists prior to being vaccinated. Without this confirmation, you CANNOT be vaccinated by Park Chemists.

The New York State COVID-19 Vaccine Form is expected to take less than 2 minutes to complete and can be found in the following link: vaccineform.health.ny.gov