Additional mRNA COVID-19 Vaccine Dose Attestation

Additional mRNA COVID-19 Vaccine Dose Attestation


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Attest to my need for an additional dose of an mRNA COVID-19 vaccine based on being considered moderately or severely immunosuppressed based on one or more of the following conditions, treatments or diagnosis.

•        Immune compromised due to undergone solid organ transplantation and taking immune suppressing medications

•        Immune compromised due to active treatment for solid tumor and hematologic malignancies

•        Immune compromised due to receipt of CAR-T cell or hematopoietic stem cell transplant (within 2 years of transplantation or taking immunosuppression therapy)

•        Moderate to severe primary immunodeficiency (e.g., DiGeorge, Wiskott-

Aldrich Syndromes)

·         Immune compromised due to Advanced or untreated HIV infection

•    Immune compromised due to "Active treatment with high-dose corticosteroids or other drugs that may suppress immune response: high-dose corticosteroids (i.e..,  20 mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor necrosis (TNF) blocker or other biologic agents that are immunosuppressive or immunomodulatory "

"l furthermore attest that I have previously received a two-dose series of an mRNA COVID-19 vaccine (Pfizer BioNTech or Moderna).


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