Certification
Form Instructions
This
form is to be used to identify individuals who are
members of a U.S. Department of Health and Human Services
(HHS)-approved smallpox emergency response Plan (a
Plan) who received a smallpox vaccination under that
Plan. It is to be used by smallpox vaccine recipients,
vaccinia contacts, survivors of smallpox vaccine recipients
or vaccinia contacts, their estates, or personal representatives
of anyone requesting benefits under the Smallpox Vaccine
Injury Compensation (SVIC) Program to certify that
the smallpox vaccine recipient met certain eligibility
criteria of the Smallpox Emergency Personnel Protection
Act of 2003.
Include
the Certification Form in your Request Package.
CHANGES
IN INFORMATION PROVIDED
For
changes in the information provided in this Certification
Form, notify in writing as soon as possible:
SVIC
Program Office at
5600 Fishers Lane,
Room 11C-26,
Rockville, MD 20857.
FILLING
OUT THE CERTIFICATION FORM
Please type or print clearly all information requested.
SECTION
1 Instructions
This section describes the individual who is/was a
member of a Plan and who received a smallpox vaccination
under that Plan.
Name:
The full name of the individual who received the smallpox
vaccine.
Social Security Number: That individual’s
9-digit Social Security number, if known.
Address: That individual’s current
home address.
City: That individual’s current city
of residence.
State: That individual’s current
state of residence.
Zip Code: The 5 or 9 digit zip code
for that individual’s current residence.
Date of Smallpox Vaccination administered
under the response plan: The date the individual
received a smallpox vaccination as part of a Plan.
Check the box that best describes the emergency
response role of the individual who was vaccinated:
The Act lists the job categories for individuals in
smallpox emergency response plans. Check the one category
that best describes the individual who received the
smallpox vaccination. If the individual is a support
worker for any of the named categories, check that
box and write in the type of support work (e.g., janitor).
SECTION
2 Instructions
This section describes the Smallpox Emergency Response
Plan entity and the certifier on its behalf.
Name of Representative: The name of the individual
who represents the entity that administered the smallpox
vaccine under an HHS-approved smallpox emergency response
plan.
Name of entity: The name of the certifying
entity (e.g., a hospital, a fire department, a county
health department, etc.)
Address: The entity’s business address.
City: The entity’s city.
State: The entity’s state.
Zip Code: The entity’s 5 or 9 digit
zip code.
Telephone Number: The certifier’s
daytime telephone number, including the area code,
and extension.
This entity participated in the administration
of the smallpox vaccine through an HHS-approved smallpox
emergency response plan and is best described as (check
one): Check the box that best describes the
entity (e.g., the U.S. Department of Health and Human
Services, State government, local government, Private
health care entity). If other, please describe.
Smallpox emergency response plan in which
he or she was/is a member: The individual’s
plan (e.g., the State of Minnesota’s smallpox emergency
response plan)
Signature of the individual signing on behalf
of the entity: to be signed by the certifier,
not the individual who received the vaccine, certifying
that the individual who received the smallpox vaccine
is/was a member of, and received the smallpox vaccine
under, a Plan.
Title: The job title of the certifier.
Date: The date the certifier signed
the Certification Form.
By
signing Section 2, the certifier is attesting under
penalty of prosecution that all statements in the
Certification Form are true and accurate to the best
of his or her knowledge.
Contact:
smallpox@hrsa.gov
or 1-888-496-0338
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