DOH COVID-19 Vaccine Informed Consent Form and Fact Sheet
The New York State Department of Health (NYSDOH) issued a "COVID-19 Immunization Screening and Consent Form.” The consent form is accompanied by an Information Sheet for Healthcare Professionals about the Screening Checklist that addresses the 8 screening questions. 
A fact sheet that informs the consent provider and vaccine recipient must be included with the standardized informed consent form. The FDA published a fact sheet for vaccine recipients and caregivers, and a similar fact sheet for healthcare providers administering the vaccination. These fact sheets are specifically for the Pfizer-BioNTech COVID-19 Vaccine.
There are two groups of residences in OPWDD that will receive vaccines:
  1.  Statewide 414 homes are deemed part of the long term care group – homes (IRA or ICF) of 5 or more people with an average age over 65 – that will be receiving the Pfizer vaccine through a pharmacy distribution plan. Pharmacies are likely to work directly with providers and we have heard they’ve done that in some parts of the state.
  2. The Moderna vaccine will be for all other certified OPWDD residences (IRA, ICF, supported IRAs).
Both vaccines require two shots and informed consent forms, and are for residents and staff who have regular contact in the homes. Residential programs can begin to inform those who can make decisions about the vaccines, as well as look at health records/status of residents to determine clinically who may not be eligible/a good candidate for the vaccine. 
While vaccination cannot be mandated, it is critical that use of the vaccine is encouraged and that all parties are informed on the facts of the vaccine and the vaccination program. We encourage all Affiliates to familiarize themselves with the screening forms and fact sheets. This will help expedite the informed consent process for those who are presented with the Pfizer vaccine as an option.