19 VACCINE SELF-CERTIFICATION FORM
UNDERLYING MEDICAL CONDITION(S) RELATED TO NIH COVID-19 VACCINE PRIORITIZATION
Background: The National Institutes for Health (NIH) received a limited number of COVID-19 vaccines for NIH staff. Prioritization of vaccine distribution to NIH staff is based on likely risk of workplace exposure to SARS-CoV-2 (the virus that causes COVID-19) and risk of transmission of SARS-CoV-2 to/from others in the workplace. The
NIH vaccine distribution plan prioritization is generally consistent with
CDC guidance. All staff, including contractors and trainees, are eligible to receive the vaccine within their respective priority group. Certain underlying medical conditions are thought to increase one’s risk of severe illness if they get (or acquire) COVID-19.
Instruction/Purpose: The purpose of this certification form is to offer NIH staff who have a medical condition described below, as diagnosed by a sufficiently qualified healthcare provider outside of one’s family, to inform NIH of this medical condition for the purposes of seeking a COVID-19 vaccine from NIH in advance of their usual NIH staff prioritization group. Filling out this form, and obtaining the COVID-19 vaccine at NIH, is completely voluntary. Only fill out this form if you want to be considered by NIH for elevated prioritization of NIH’s available COVID-19 vaccine. Even if you fill out this form, NIH may not be able to provide you with the COVID-19 vaccine. NIH may, at its discretion, decide not to prioritize some or all of the medical conditions listed in this form.
Please frequently check the websites for the state and county health departments where you reside to see if you may be eligible to receive a COVID-19 vaccine at a location in your county sooner than at NIH. If you do get your vaccine elsewhere, please be sure to notify Occupational Medical Service via
email so they can count you as receiving it and adjust requested numbers as appropriate.
This information will not be shared with your supervisor. It will be stored in the NIH System of Record
09-25-0216, NIH Electronic Directory, HHS/NIH and viewed only by
NIH Occupational Medical Service (OMS), and those assisting OMS, for the purpose of creating vaccine prioritization lists and notifying eligible staff.
Click Proceed below to complete the SELF-CERTIFICATION FORM: UNDERLYING MEDICAL CONDITION(S) RELATED TO NIH COVID-19 VACCINE PRIORITIZATION