SELF-CERTIFICATION FORM: UNDERLYING MEDICAL CONDITION(S) RELATED TO NIH COVID-19 VACCINE PRIORITIZATION

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.

Date Completed

M-D-Y

First Name

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Middle Name

Last Name

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Date Of Birth

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NIH ID (no dashes)

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Your NIH ID is the 10 digit number on the back of your badge. You can also find it by visiting ned.nih.gov.

State where employed

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Email:

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Preferred Phone

Certification
I certify that I have been diagnosed by a sufficiently qualified healthcare provider, who is not a family member, with one or more of the following medical conditions which are associated with increased risk for severe illness if I get (or acquire) COVID-19.

• Cancer
• Chronic kidney disease
• COPD (chronic obstructive pulmonary disease)
• Down Syndrome
• Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
• Immunocompromised state (weakened immune system) from solid organ transplant
• Obesity (body mass index [BMI] of equal to or more than 30 kg/m2 but less than 40 kg/m2)
• Severe Obesity (BMI of equal to or more than 40 kg/m2)
• Pregnancy
• Sickle cell disease
• Smoking
• Type 2 diabetes mellitus

• Asthma (moderate-to-severe)
• Cerebrovascular disease (affects blood vessels and blood supply to the brain)
• Cystic fibrosis
• Hypertension (high blood pressure)
• Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of immune weakening (or suppressing) medicines (such as corticosteroids)
• Neurologic conditions, such as dementia
• Liver disease
• Overweight (BMI of equal to or more than 25 kg/m2, but less than 30 kg/m2)
• Pulmonary fibrosis (having damaged or scarred lung tissues)
• Thalassemia (a type of blood disorder)
• Type 1 diabetes mellitus

I certify that I am over 18 years old.

I certify that the statements I have made on this form are true, complete, and correct to the best of my knowledge. I understand that completing this form is strictly voluntary. However, if I choose to complete this form and I misrepresent, or provide false, fraudulent, or misleading information regarding this self-certification that I may be subject to disciplinary action up to and including removal from my employment with the National Institutes of Health (NIH) and/or the federal government.

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I accept this certification statement.

None of these conditions apply. Please cancel my request.

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