Life Number or Employee ID
LIFE
EMP ID (Oracle ID)
If you do not have a life number/employee ID, select LIFE and enter 'NA' in the next field.
Employee Life Number or Employee ID Number
* must provide value
Life Number or Employee ID Number should contain numerical values only. MSSN employees: Enter ID number without a letter "E" or "M". For example: if ID number is E123456 or M123456, enter 123456.
Employee First Name
* must provide value
Employee Last Name
* must provide value
Date of birth
* must provide value
M-D-Y
Employee Email (personal or work email address)
* must provide value
Telephone Number
* must provide value
Please provide so EHS can contact you if needed.
Select the primary site where you are employed and/or volunteer
* must provide value
MSBI - Mount Sinai Beth Israel
MSB - Mount Sinai Brooklyn
MSC - Mount Sinai Corporate
MSD - Mount Sinai Downtown (Union Square, Chelsea, Behavioral Health Center)
MSH - Mount Sinai Hospital
MSSN - Mount Sinai South Nassau
MSQ - Mount Sinai Queens
MSW - Mount Sinai West
MSM - Mount Sinai Morningside
NYEE - New York Eye & Ear Infirmary of Mount Sinai
Indicate your affiliation with the health system:
* must provide value
Employee
Voluntary Faculty
Student (Non-Employee)
Vendor (Non-MSHS Employee)
Volunteer
Will you be working 100% offsite from Oct 1 - Mar 31?
* must provide value
Yes
No
Please check this box if you are a vendor.
Please check this box if you are a voluntary MD.
Which Vaccine are you reporting?
Flu - I want to report a flu vaccination
Flu - I want to decline flu vaccination
Covid Vaccination
Other
Primary Covid
Covid-19 Bivalent Booster
Covid-19 Bivalent Booster
Covid-19 vaccine- Primary Series
Hepatitis B
Tdap
MMR
Varicella
I want to report a flu vaccination
I want to decline flu vaccination
New hires who signed an agreement to take the flu vaccine should review the email they have been sent regarding flu vaccination.
I ATTEST THAT I HAVE READ AND UNDERSTAND THE FOLLOWING:
Influenza vaccine does not give me the flu; rather the flu vaccine helps to prevent or lessen flu symptoms.The flu is a serious illness . My refusal to be vaccinated could be life-threatening to my health and the health of everyone I have contact with -- including my coworkers, patients, and my friends/family. The flu vaccine is strongly recommended for me and all healthcare personnel to protect our staff and our patients from the flu, its complications, and death. If I become ill with the flu: I can be contagious 48 hours before any symptoms appear. During this time, I can transmit the flu to my patients, my family, and to staff in this facility. Even if my symptoms are mild or non-existent, I can still spread the flu virus to others. The strains of flu virus change frequently, and immunity declines over time . This is why vaccination against the flu is offered annually. There are only THREE (3) valid medical reasons not to receive the flu vaccine: Life threatening/severe allergy to vaccine components Severe reaction to a previous influenza vaccine History of Guillain-Barre Syndrome (GBS) Nevertheless, I have decided NOT to receive the flu vaccine and agree to wear a surgical mask , covering both my mouth and nose, at all times while on any MSHS campus, inpatient or outpatient clinic where patients may be present until flu season ends. I understand that even though I am declining the vaccine now, I can change my mind at any time and get vaccinated by contacting EHS, local pharmacy, or my health provider My reason for not receiving the influenza vaccine is:
Currently Ill/Medically Compromised
"I am currently ill/recovering from illness."
Personal Preference
"The flu vaccine does not work that well." "My natural immune system is enough." "I'm against vaccines." "I don't need it." "I wear a mask anyway."
Previous Documented Severe Reaction/Medical Contraindication
"I have a documented past severe allergic reaction." "I have documented medical contraindication to receiving the flu vaccine."
Religious Belief
"I have a religious exemption to vaccines." "It does not align with my religious beliefs."
Vaccine Concerns
"The vaccine makes me sick." "I am uncomfortable with the vaccine ingredients, needles, or receiving yet another vaccine."
Select a reason below:
NOTE: If you have already received this year's influenza vaccine from an external source, you are required to submit the medical documentation from your primary care provider/licensed pharmacist to EHS (see email addresses above) or submit to REDCap: https://redcap.link/employeevaccinationstatus .
1-Dec
* must provide value
I have a valid medical contraindication (see above for accepted reasons)
I have safety concerns
Currently Ill/Medically Compromised
Personal Preference
Previous Documented Severe Reaction/Medical Contraindication
Religious Belief
Vaccine Concerns
Other reason
Please indicate whether you are partially vaccinated, fully vaccinated or boosted. - Select Partially vaccinated if you have received only your first dose of Pfizer or Moderna - Select Fully vaccinated if you have received your second dose of Pfizer or Moderna or first dose of Johnson & Johnson -Select Booster if you are reporting having received a booster of Pfizer or Moderna or Johnson & Johnson
* must provide value
Partially vaccinated
Fully vaccinated
Booster #1
Booster #2
For the Vaccine you are reporting, did you receive it at a MSHS facility?
If you received your vaccine at MSSN, Elmhurst, Queens Hospital Center OR outside of MSHS (e.g. local pharmacy, State vaccine site, out-of-state or other health system), please select "No" .
* must provide value
Yes
No
If vaccinated at MSSN, please select No.
Do you give MSHS permission to download your Vaccine information from Epic? If 'No', you may upload another form of proof.(Note: No additional personal health information will be accessible as part of this process).
* must provide value
Yes
No
Please indicate which type of proof of vaccine you are uploading:
CDC COVID-19 Vaccination Record Card
Excelsior Pass
Vaccinated Outside of the United States
I am partially vaccinated at this time
I am not vaccinated at this time
Date of First Dose of Vaccine Received (today or prior to today):
* must provide value
M-D-Y
Date of Second Dose of Vaccine (Received or Scheduled):
M-D-Y
M-D-Y
M-D-Y
Date of Vaccination:
* must provide value
M-D-Y
Country where vaccinated:
* must provide value
Which vaccine did you receive?
* must provide value
Pfizer
Moderna
J&J
Novavax
Other
If Other, please specify:
Please upload proof of vaccination documentation (if fully or partially vaccinated):
NOTE: The uploaded picture has to clearly display your name, DOB vaccine type & vaccine date(s) and should be in JPG/JPEG, PNG or PDF format.
For instructions on taking screen shots on mobile devices, click the links below:
On Apple Devices
On Android Devices
Add the image by clicking "Upload File" and selecting the image from your device's photo album.
* must provide value
I wish to decline the vaccine
FOR EHS USE: EHS site contacts:
FOR EHS USE: No matching life number in both Sinai Cloud employee master and Cority Emp master
FOR EHS USE: Emailed employee for follow-up
FOR EHS USE: Date emailed employee for follow-up
M-D-Y
EHS Follow-up: Date of Call #1
M-D-Y
EHS Follow-up: Date of Call #2
M-D-Y
FOR EHS USE: Lost to follow-up - unable to contact employee
FOR EHS USE: Please clarify why case was marked as lost to follow-up (select one):
* must provide value
Cannot contact employee/employee unresponsive
Duplicate case
Documentation invalid - employee instructed to resubmit
Employee terminated
M-D-Y
BOOSTED-1
Partially Vaccinated - Resubmitted full vaccination [FOR BACK END USE]
Yes
No
Booster - Send One-time Notification
Yes
No
Booster - Y-Y Queue Send One-time Notification
Yes
No
Booster - Y-Y Queue 2nd Notification
Yes
No
Booster - Y-Y No Response - EHS follow-up
Yes
No
Booster - Y-Y No Response - EHS follow-up Final Email
Yes
No
Booster - No Response - Manager Email
Yes
No
Vax Doc Name - FOR REPORT USE
View equation Yes
No