COVID-19 Vaccination – Additional Dose / Booster Form

Additional Dose/Booster Registration
A COVID booster shot is an additional dose of a vaccine given after the protection provided by the original shot(s) has begun to decrease over time. Typically, you would get a booster after the immunity from the initial dose(s) naturally starts to wane. The booster is designed to help people maintain their level of immunity for longer.

You may qualify for a COVID-19 Booster shot if:
- - You are 12 years or old and received your 2nd shot of the Pfizer COVID-19 vaccine at least 5 months ago;
  - You are 18 years or older and received your 2nd shot of the Moderna COVID-19 vaccine at least 5 months ago;
  - You are 18 years or older and received your Janssen/Johnson & Johnson vaccine at least 2 months ago;
  - Vaccine preference for booster/3rd dose is based on vaccine availability.
  - No additional booster doses beyond what is currently authorized by the CDC and FDA will be provided. For more information, please visit www.cdc.gov
Island Location*
Saipan - Location*
If no spots are available, all spots have been filled. Please check back at a later time to see if additional spots are available.

View Schedule and Requirements
Tinian - Location*
If no spots are available, all spots have been filled. Please check back at a later time to see if additional spots are available.

View Schedule and Requirements
Rota - Location*
If no spots are available, all spots have been filled. Please check back at a later time to see if additional spots are available.

View Schedule and Requirements
HOMEBOUND/OTHER LOCATION - (For Official Use Only)**
Please format as follows: 01/05 - Location
Official Use Code*
COTA TRANPORT
Do you need public transport to the vaccination site?*
- Yes
- No
TRANSPORT DETAILS
Will you require an escort? (Only 1 escort is allowed)*
- Yes
- No
Do you require special assistance to on-board/off-board the vehicle?*
- Yes
- No
Please list any special accomodations and location of your residence*

Name and Contact Information
Full Name*
First Middle Last
Date of Birth*
MM
DD
YYYY
Age
You must be 5 years or older to register for an additional/booster dose.
Phone Number*
Email Address
COVID-19 Vax Info
Were you ever vaccinated for COVID-19 in the CNMI?*
- Yes
- No
HEALTH RECORD NO./COVID-19 VAX ID
Your Health Record Number/COVID-19 VAX ID can be found on your vaccination card.
What COVID-19 vaccine did you receive last?*
Date of last COVID-19 Vacciation
MM
DD
YYYY
COVID-19 Vaccination Document
If vaccinated for COVID-19 outside of the CNMI, please provide any documentation you may have of your COVID-19 vaccination.

EUA - FACT SHEET FOR RECIPIENTS AND CAREGIVERS
Please take time to review the EUA - FACT SHEET FOR RECIPIENTS AND CAREGIVERS (Pfizer) - Click Here

Please take time to review the EUA - FACT SHEET FOR RECIPIENTS AND CAREGIVERS (Moderna) - Click Here

Please take time to review the EUA - FACT SHEET FOR RECIPIENTS AND CAREGIVERS (Janssen) - Click Here
Additional Dose / Booster Consent*
If I experience any adverse reactions after leaving, I will notify my primary care provider. I have viewed the Emergency Use Authorization (EUA) Fact Sheet or Vaccine Information Statement (VIS) provided to me today. I understand the benefits and risks of the vaccine.

I understand that patients may receive an additional dose or booster dose of the same vaccine product or substitute another COVID-19 vaccine product authorized by the FDA.

By consenting to this form, I give permission for an additional COVID-19 vaccine to be administered and a record of the vaccination to be entered into the CNMI Immunization Information System (WebIZ) for care coordination and to monitor statewide vaccination coverage.
I UNDERSTAND AND AGREE

Vaccinate CNMI

THE COVID-19 VACCINATION FORM IS UNDERGOING MAINTENANCE.

Additional Dose/Booster Registration

Step 1 of 4

COVID-19 History Questionnaire

Notice: For the safety of our community and staff, do not visit the COVID-19 Vaccination site until after 10 days of your positive test result and/or quarantine guidelines are met.

Additional Dose/Booster Registration

You may qualify for a COVID-19 Booster shot if:

COTA TRANPORT

TRANSPORT DETAILS

Name and Contact Information

You must be 5 years or older to register for an additional/booster dose.

COVID-19 Vax Info

EUA - FACT SHEET FOR RECIPIENTS AND CAREGIVERS

Contact Us

The number utilized by the VaccinateCNMI Call Center is proudly sponsored by IT&E through community partnership with the Governor's COVID-19 Task Force.

#VACCINATECNMI

Schedule and Requirements

Vaccination varies by location and availability. We are currently not accommodating vaccine preference requests. LAST CALL is the time the last vaccine will be given to a checked-in patient.

Saipan - CHCC Immunization Clinic

COVID-19 Provider Sites: Marianas Medical Center, Kagman Isla Community Center, Medical Associates of the Pacific, Family Care Clinic, Women's Clinic, and Childrens Clinic

Tinian Health Center

Rota Health Center

WHAT TO BRING

Vaccinate CNMI

THE COVID-19 VACCINATION FORM IS UNDERGOING MAINTENANCE.

Additional Dose/Booster Registration

Step 1 of 4

COVID-19 History Questionnaire

Notice: For the safety of our community and staff, do not visit the COVID-19 Vaccination site until after 10 days of your positive test result and/or quarantine guidelines are met.

Additional Dose/Booster Registration

You may qualify for a COVID-19 Booster shot if:

COTA TRANPORT

TRANSPORT DETAILS

Name and Contact Information

You must be 5 years or older to register for an additional/booster dose.

COVID-19 Vax Info

EUA - FACT SHEET FOR RECIPIENTS AND CAREGIVERS

Contact Us

The number utilized by the VaccinateCNMI Call Center is proudly sponsored by IT&E through community partnership with the Governor's COVID-19 Task Force.

#VACCINATECNMI

Schedule and Requirements

Vaccination varies by location and availability. We are currently not accommodating vaccine preference requests. LAST CALL is the time the last vaccine will be given to a checked-in patient.

Saipan - CHCC Immunization Clinic ​

COVID-19 Provider Sites: Marianas Medical Center, Kagman Isla Community Center, Medical Associates of the Pacific, Family Care Clinic, Women's Clinic, and Childrens Clinic

Tinian Health Center

Rota Health Center

WHAT TO BRING

Saipan - CHCC Immunization Clinic