NYPSmartVax - Vaccine Submission/Exemption Request Form

Staff Type

Site Affiliation

Last Name

First Name

Date of Birth

mm/dd/yyyy

Email Address

Confirm that your email address is correct before submitting this request, as it may impact your receipt of notifications regarding your submission.

Phone Number

Please provide the best contact number to reach you below.

Phone

Acknowledgement

By signing below, I authorize Workforce Health & Safety to contact my healthcare provider to discuss my medical condition related to this request, if necessary.

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