The code block below illustrates how one might use # and // as comments in your logic and calculations.

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This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

222zI2TW8zxkqJm5rKBUDotXtHLER3BpRieiin7RhPLSHZpwo3FG3BVwDbQCjomSt8iGvcYHIfNhcLsduGbKf8XtBsYvTaNb

Employee Vaccination Status

After your submission, a verification email will come from DWHPBAT@MSHMVSA.mountsinai.org or redcap-noreply@mssm.edu. If you cannot locate your confirmation, please check your junk mail.

Life Number or Employee ID

LIFE

EMP ID (Oracle ID)

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Employee Life Number

* must provide value

Employee ID (Oracle ID)

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

Primary Site

* must provide value

MSBI - Mount Sinai Beth Israel

MSB - Mount Sinai Brooklyn

MSC - Mount Sinai Corporate

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

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Please check this box if you are a vendor.

I am a MSHS vendor

Please check this box if you are a voluntary MD.

I am a voluntary MD at Mount Sinai South Nassau (MSSN)

Which Vaccine are you reporting?

Flu - I want to report a flu vaccination

Flu - I want to decline flu vaccination

Covid Vaccination

Other

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flu2

I want to report a flu vaccination

I want to decline flu vaccination

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Flu vaccine fact

Attachment:Flu Vaccine Facts.pdf

I attest that I have read and understand:

1) The influenza vaccine is strongly recommended for all workers in healthcare facilities.

2) The significant benefits of receiving the influenza vaccine.

3) The requirement to wear a surgical mask in all clinical areas and areas where patients may be present (e.g., elevators, cafeteria, building lobbies).

4) There are only THREE (3) valid medical reasons not to receive the influenza 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 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:

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:

vaccination declination

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

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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

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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

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Please indicate which type of proof of vaccine you are uploading:

CDC COVID-19 Vaccination Record Card

Vaccinated Outside of the United States

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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

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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

Upload file

I wish to decline the vaccine

FOR EHS USE:

EHS site contacts:
MSH: employee.health@mountsinai.org
MSBI/NYEE/MSB: employeehealthservices2@mountsinai.org
MSW: ehsphysicalsmsw@mountsinai.org
MSM: ehsphysicalsmssl@mountsinai.org
MSQ: employeehealthmsq@mountsinai.org

Data uploaded to Cority/Onbase and emailed to EHS site

FOR EHS USE: No matching life number in both Sinai Cloud employee master and Cority Emp master

Not able to cross match to Cority

FOR EHS USE: Emailed employee for follow-up

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

Lost to follow-up

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

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EHS Comments:

Expand

Survey Date

M-D-Y

Supervisor Email

Vax Status:

Partially Vaccinated - Resubmitted full vaccination [FOR BACK END USE]

Yes

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Booster - Send One-time Notification

Yes

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Booster - Y-Y Queue Send One-time Notification

Yes

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Booster - Y-Y Queue 2nd Notification

Yes

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Booster - Y-Y No Response - EHS follow-up

Yes

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Booster - Y-Y No Response - EHS follow-up Final Email

Yes

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Booster - No Response - Manager Email

Yes

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Vax Doc Name - FOR REPORT USE

View equation

Send HEIC Notification

Yes

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Duplicate

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.