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
* must provide value
If you do not have a life number, enter 'NA'.
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.
Please check this box if you are a vendor.
Which Vaccine are you reporting?
Flu - I want to report a flu vaccination
Flu - I want to decline flu vaccination
Primary Covid
Covid-19 Bivalent Booster
2023-24 Covid Vaccination
Other
Covid-19 Bivalent Booster
Covid-19 vaccine- Primary Series
Hepatitis B
Tdap
I want to report a flu vaccination
I want to decline flu vaccination
1-Dec
* must provide value
I have a valid medical contraindication (see above for accepted reasons)
I have safety concerns
Other reason
Please indicate whether you are partially vaccinated, fully vaccinated or boosted.Partially vaccinated if you have received only your first dose of Pfizer or ModernaFully vaccinated if you have received your second dose of Pfizer or Moderna or first dose of Johnson & JohnsonBooster 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
Date of Booster:
* must provide value
M-D-Y
Date of Booster:
* must provide value
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
FOR EHS USE: EHS site contacts:
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
ISM 42nd St MSB MSBI MSH MSM MSW MSSN MSQ MSD Elmhurst NYEE Queens Hospital Center
I wish to decline the vaccine
I attest that I have read and understand:
The influenza vaccine is strongly recommended for all workers in healthcare facilities. The significant benefits of receiving the influenza vaccine. The requirement to wear a surgical mask in all clinical areas and areas where patients may be present (e.g., elevators, cafeteria, building lobbies). There are only THREE (3) valid medical reasons not to receive the influenza vaccine: a.Life threatening/severe allergy to vaccine components
b.Severe reaction to a previous influenza vaccine
c.History of Guillain-Barre Syndrome (GBS)
Nevertheless, I have decided NOT to receive the influenza vaccine. I understand that even though I am declining the vaccine now, I can change my mind at any time and accept vaccination in the future by contacting EHS.
My reason for not receiving the influenza vaccine is (check one):
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