New York State COVID-19 Vaccine Form

This is the NY State Vaccination form

Steps to getting your shot

Schedule your Appointment

Click the time and date you would like to get your shot. 

Fill out NY State Form

Fill out the NY State

Bring picture or proof of NY state registration 

Date of Immunization

Arrive 15 Minutes Early

Bring Insurance Card

Licence and

Proof of Qualification Persons

(work badge, healthcare provider script, pay stub)

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NY State Qualification

  • First Responder or Support Staff for First Responder Agency

    • Fire

      • 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

      • SUNY Police

      • Sheriffs' Offices

      • 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, OCFS, SLA

    • 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

  • Corrections

    • 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 Schools

    • 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

  • Public facing grocery store workers, including convenience store, bodegas, regional food banks, food pantries, and permitted home-delivered meal programs

  • 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 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.

  • 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