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.

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