Louisiana COVID-19 Vaccination Self-Attestation Form
This file provides information on COVID-19 vaccine eligibility in Louisiana. It includes instructions on completing and submitting the vaccination self-attestation form. Individuals with certain health conditions may qualify for vaccination under Phase 1b.
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How do I fill this out?
To fill out this form, start by reviewing the list of high-risk medical conditions. Next, check the conditions that apply to you. Finally, sign and date the form before bringing it to your vaccination appointment.
How to fill out the Louisiana COVID-19 Vaccination Self-Attestation Form?
1
Review the list of high-risk medical conditions.
2
Check all applicable conditions that apply to you.
3
Fill in your name, date, and signature.
4
Print the form for your records.
5
Bring it to your vaccination appointment.
Who needs the Louisiana COVID-19 Vaccination Self-Attestation Form?
1
Individuals aged 55 and older with health conditions need this form to qualify for the COVID-19 vaccine.
2
Pregnant women need it to attest to their eligibility for vaccination.
3
People with chronic conditions like heart disease and diabetes need it to ensure they can receive the vaccine.
4
Those who have experienced organ transplants may require this form as part of their vaccination process.
5
Patients with obesity or other qualifying medical issues must submit this form to access vaccination.
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What are the important dates for this form in 2024 and 2025?
Please be aware that the eligibility for vaccination may change as guidelines are updated. Keep an eye on announcements from the Louisiana Department of Health for important dates regarding vaccinations. Check back often for the most current information.
What is the purpose of this form?
The purpose of this form is to ensure that individuals with high-risk medical conditions can access the COVID-19 vaccine. It allows eligible persons to declare their health status for vaccination purposes. By filling out the form, you can confirm your eligibility and ensure a smoother vaccination process.
Tell me about this form and its components and fields line-by-line.
- 1. Name: Your full name.
- 2. Date: The date you are filling out the form.
- 3. High-risk conditions: List of high-risk conditions to check.
- 4. Signature: Your signature confirming the information.
What happens if I fail to submit this form?
Failing to submit this form may result in missing out on your eligibility for the COVID-19 vaccine. It is essential to present this form at your vaccination site to confirm your health conditions. Without it, you may not be allowed to receive the vaccine based on the guidelines.
- Missed Vaccination: You may not be permitted to receive the vaccine without proper documentation.
- Ineligibility: Failure to indicate high-risk status could result in being deemed ineligible.
- Delays: Not having the form ready could delay your vaccination appointment.
How do I know when to use this form?
- 1. High-risk Individuals: Those with specific health conditions should utilize this form to declare their vaccine eligibility.
- 2. Healthcare Workers: Healthcare professionals may need this to assist patients.
- 3. Pregnant Women: Pregnant women must use this form to confirm eligibility.
- 4. Patients with Chronic Conditions: Patients with chronic diseases need to fill out this form.
- 5. Vaccination Sites: Vaccination sites will request this form to verify eligibility.
Frequently Asked Questions
How do I fill out the vaccination form?
Start by reviewing the medical conditions list and checking the applicable ones. Sign and date the form before attending your appointment.
Can I edit the PDF before printing?
Yes, you can make edits to the PDF using our PrintFriendly editor.
How do I submit the vaccination form?
Bring the completed form to your vaccination appointment.
What if I need to update my information?
You can edit your PDF to make necessary updates before printing.
Can I share my completed form electronically?
Absolutely, you can use our features to share your form via email or social media.
Is an electronic signature acceptable?
Yes, you can sign the document electronically in our editor.
What should I do after filling out the form?
Ensure to print and bring the form to your vaccination site.
Will I get confirmation after submission?
This form is for bringing to your appointment, so you will not receive a confirmation.
Can I download the form after editing?
Yes, you can download the edited form for your records.
Is there a deadline for submitting this form?
Make sure to bring the form with you on the day of your vaccination.
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