Register as COVID-19 Vaccinator

Register as COVID-19 Vaccinator

This registry is only for those healthcare professionals identified in the Order issued by Acting Commissioner On December 7, 2020, link to order:

Podiatrists
Dentists
Dental hygienists, provided they have training to administer dental anesthesia
Veterinarians
Advanced emergency medical technicians
Emergency medical technicians, provided they have previously completed the Department of Public Health (DPH) approved intramuscular epinephrine administration training
Paramedics

This authorization limits such person to providing vaccination under the auspices of a COVID-19 vaccine provider which is enrolled in the federal COVID-19 Vaccination Program through the Department.

Other classes of healthcare professionals are already approved to administer vaccinations, including physicians, physician assistants, APRNs, registered nurses and licensed practical nurses.

* - Required Field

Last Name*

First Name*

Email Address*

Phone Number*

License Class*

Is your license in good standing with DPH?*

Yes No Other

Other*

If a dental hygienist, do you have training to administer dental anesthesia?*

Yes No Not Applicable

If an emergency medical technician, do you have training to administer epinephrine by intramuscular injection?*

Yes No Not Applicable

Do you wish to be contacted by vaccination points of distribution and or mass vaccination clinic?*

Yes No

Counties in which you are interested in serving as a vaccinator (select all that are applicable) *

Hours in which you are willing to work (Select all that apply)*

Days
Evenings
Weekends
All of the Above

Upload a copy of your training certificate from a DPH approved Vaccination Training program*

Upload a copy of your Vaccination Skills Verification form*

Upload a copy of your CDC training modules certificate*

* I attest that the information provided by me in this application is true in every respect. I understand that a person is guilty of false statement in the second degree when a person intentionally makes a false written statement under oath or pursuant to a form bearing notice, authorized by law, to the effect that false statements made therein are punishable, which he/she does not believe to be true and which statement is intended to mislead a public servant in the performance of his/her official function. A false statement in the second degree is a class A misdemeanor. By clicking submit below, I attest that all information entered by me is true and accurate.