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The Am I Eligible Form
What is the Am I Eligible form?
What is the form?
•
A tool for
scheduling
vaccine appointments. If eligible, the tool will provide a list of providers
(including state vaccination sites) where the NYS resident can schedule an appointment
•
The
final say
for whether or not someone will or will not receive the vaccine
•
A
tool for businesses
to assess whether they can schedule vaccinations for their employees
What the form is NOT?
An assessment tool for individuals to indicate if they may
currently
be eligible for the
COVID-19 vaccine. The form will be on the public NY vaccine website, anyone will be able to
use it and enter an address, though it will only show providers located in New York.
The
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The Am I Eligible Form
The Am I Eligible form includes 4 sections:
Section 1: About You
Section 2: Contact Information
Section 3: Additional Information
Section 4: Acknowledgment
Details on each section will be included in the following slides.
Click
‘Get Started’
to open the Am I Eligible form.
Note: the Am I Eligible tool is currently available in two languages: Englishand Spanish. Click on the
Section 1:
About You
• First Name: First Names should be entered as they are displayed on your ID documentation (Passport, Drivers License, Birth Certificate, SSN card, Permanent Resident Card)
• Last Name: Last Names should be entered as they are displayed on your ID documentation (Passport, Drivers License, Birth Certificate, SSN card, Permanent Resident Card)
• Date of Birth: You should populate date of birth in the MM/DD/YYYY format • Sex: Male/Female/Non-Binary/Prefer Not to Answer
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Section 2:
Contact Information
You should complete the form to the best of your ability based on your background, residence, and current occupation.
• Address: You should use your current residence (if eligible, the tool will populate providers based on zip code
entered)
• Preferred Contact Language: You must select has English, Spanish, Chinese, Russian, Haitian-Creole, Bengali, Korean
• Preferred Method of Contact: One of the two options (Text Message/ Email) must be selected • Email Address: Required if ‘contact preference’ is selected as ‘Email’
• Mobile Phone Number: Required if ‘contact preference’ is selected as ‘‘Text Message’
• Participation: Select yes/no if you would like to receive text messages or emails about administration of the COVID-19 vaccine
Section 3:
Additional Information
• Are you a State employee, Local government employee, or Employee of a Public Authority?: You should select ‘Yes’ or ‘No’ according to their current occupation.
• Are you a worker in a patient-facing healthcare setting or a congregate living setting?: You should select ‘Yes’ or ‘No’ according to your current occupation. If you select Yes,you will be required to select between the following: hospital, emergency medical service, ambulatory and outpatient care, private provider clinic or office, FQHC (community-based health center), congregate setting (e.g. nursing home, group home, skilled nursing, adult care), center for people with developmental disabilities, substance use disorder and serious illness treatment facility, pharmacy, COVID testing or vaccination site, home care, personal care, consumer directed personal care, hospice, none of the above
Note, the form will be updated as phases continue for the vaccine.
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Section 3:
Additional Information
• Are you a First Responder or Support Staff for First Responder Agency?: You should select ‘Yes’ or ‘No’
according to their current occupation. If you select Yes,you will be required to select between the following: State Fire Service, including firefighters and investigators (professional and volunteer), Local Fire Service, including
firefighters and investigators (professional and volunteer), 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, Emergency Communication and PSAP Personnel, including dispatchers and technicians, Court Officers, Other Police or Peace Officer, Support or Civilian Staff for Any of the Above Services, Agencies, or Facilities, none of the above
• Are you employed by a Corrections Agency?: You should select ‘Yes’ or ‘No’ according to your current
occupation. If you select Yes,you will be required to select between the following: 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, none of the above
Note, the form will be updated as phases continue for the vaccine.
Section 3:
Additional Information
• Are you employed in a P-12 school or school district?: You should select ‘Yes’ or ‘No’ according to their current
occupation. If you select Yes,you will be required to select between the following: P-12 school 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 and registered day care, none of the above
• Are you an employee or support staff in a licensed or registered childcare setting?: You should select ‘Yes’
or ‘No’ according to your current occupation.
• Are you a licensed or registered childcare provider?: You should select ‘Yes’ or ‘No’ according to your current
occupation.
Note, the form will be updated as phases continue for the vaccine.
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Section 3:
Additional Information
• Are you a Public Transit Employee?: You should select ‘Yes’ or ‘No’ according to their current occupation. If you
select Yes,you will be required to select between the following: 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, none of the above
• Are you currently living in a congregate setting?: You should select ‘Yes’ or ‘No’ according to your current living environment; if you select Yes,you will be required to select between the following: nursing home/ skilled nursing facility/ adult care facility/ assisted living facility, group home / community residence, behavioral health facilities, substance use disorder and serious mental health treatment facility, 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, none of the above
Note, the form will be updated as phases continue for the vaccine.
Section 4:
Acknowledgment
• Acknowledgement: The acknowledgement must be checked to ‘I consent’ in order to press the ‘submit’
button. If you do not agree, the form will not be submitted.
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