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Certificate to-identify-individuals-with-co-morbidities-that-enhance-the-risk-of-mortality-in-covid-19-disease-for-priority-vaccination

B
Balika Kumar

This document is a certificate for identifying individuals with comorbidities that increase the risk of mortality from COVID-19 for priority vaccination. It requires a registered medical practitioner to review the named individual and certify if they have any qualifying conditions based on medical records. Twenty conditions are listed that would prioritize the individual for vaccination if present, including heart disease, stroke, diabetes, kidney or liver disease, respiratory disease, cancer, immunodeficiency disorders, and disabilities. The medical practitioner must sign and date the certificate along with their registration number.

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Annexure 1(B): Certificate to identify individuals with co-morbidities that enhance the risk of mortality in COVID-19 disease for priority vaccination (To be filled by a Registered Medical Practitioner) Name of beneficiary: Age: Gender: Address: Mobile phone number: Identification document: I, Dr. _________________________________, working as ___________________________ have reviewed the above named individual and certify that he/she has the below mentioned conditions based on the records presented to me. A copy of the records on which this certificate is based is attached. Presence of ANY ONE of the following criteria will prioritize the individual for vaccination SN Criterion Yes/No 1. Heart Failure with hospital admission in past one year 2. Post Cardiac Transplant/Left Ventricular Assist Device (LVAD) 3. Significant Left ventricular systolic dysfunction (LVEF <40%) 4. Moderate or Severe Valvular Heart Disease 5. Congenital heart disease with severe PAH or Idiopathic PAH 6. Coronary Artery Disease with past CABG/PTCA/MI AND Hypertension/Diabetes on treatment 7. AnginaAND Hypertension/Diabetes on treatment 8. CT/MRI documented stroke AND Hypertension/Diabetes on treatment 9. Pulmonary artery hypertension AND Hypertension/Diabetes on treatment 10. Diabetes (> 10 yearsORwith complications) AND Hypertension on treatment 11. Kidney/ Liver/ Hematopoietic stem cell transplant: Recipient/On wait-list 12. End Stage Kidney Disease on haemodialysis/ CAPD 13. Current prolonged use of oral corticosteroids/ immunosuppressant medications 14. Decompensated cirrhosis 15. Severe respiratory disease with hospitalizations in last two years/FEV1 <50% 16. Lymphoma/ Leukaemia/ Myeloma 17. Diagnosis of any solid cancer on or after 1st July 2020 Orcurrently on any cancer therapy 18. Sickle Cell Disease/ Bone marrow failure/ Aplastic Anemia/ Thalassemia Major 19. Primary Immunodeficiency Diseases/ HIV infection 20. Persons with disabilities due to Intellectual disabilities/ Muscular Dystrophy/ Acid attack with involvement of respiratory system/ Persons with disabilities having high support needs/ Multiple disabilities including deaf-blindness I am aware that providing false information is an offence. Name of RMP:__________________ Medical Council registration number of RMP: ____________ Date of issuing the certificate: ____________ Place of issue: _________________. (Signature of RMP)

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Certificate to-identify-individuals-with-co-morbidities-that-enhance-the-risk-of-mortality-in-covid-19-disease-for-priority-vaccination

  • 1. Annexure 1(B): Certificate to identify individuals with co-morbidities that enhance the risk of mortality in COVID-19 disease for priority vaccination (To be filled by a Registered Medical Practitioner) Name of beneficiary: Age: Gender: Address: Mobile phone number: Identification document: I, Dr. _________________________________, working as ___________________________ have reviewed the above named individual and certify that he/she has the below mentioned conditions based on the records presented to me. A copy of the records on which this certificate is based is attached. Presence of ANY ONE of the following criteria will prioritize the individual for vaccination SN Criterion Yes/No 1. Heart Failure with hospital admission in past one year 2. Post Cardiac Transplant/Left Ventricular Assist Device (LVAD) 3. Significant Left ventricular systolic dysfunction (LVEF <40%) 4. Moderate or Severe Valvular Heart Disease 5. Congenital heart disease with severe PAH or Idiopathic PAH 6. Coronary Artery Disease with past CABG/PTCA/MI AND Hypertension/Diabetes on treatment 7. AnginaAND Hypertension/Diabetes on treatment 8. CT/MRI documented stroke AND Hypertension/Diabetes on treatment 9. Pulmonary artery hypertension AND Hypertension/Diabetes on treatment 10. Diabetes (> 10 yearsORwith complications) AND Hypertension on treatment 11. Kidney/ Liver/ Hematopoietic stem cell transplant: Recipient/On wait-list 12. End Stage Kidney Disease on haemodialysis/ CAPD 13. Current prolonged use of oral corticosteroids/ immunosuppressant medications 14. Decompensated cirrhosis 15. Severe respiratory disease with hospitalizations in last two years/FEV1 <50% 16. Lymphoma/ Leukaemia/ Myeloma 17. Diagnosis of any solid cancer on or after 1st July 2020 Orcurrently on any cancer therapy 18. Sickle Cell Disease/ Bone marrow failure/ Aplastic Anemia/ Thalassemia Major 19. Primary Immunodeficiency Diseases/ HIV infection 20. Persons with disabilities due to Intellectual disabilities/ Muscular Dystrophy/ Acid attack with involvement of respiratory system/ Persons with disabilities having high support needs/ Multiple disabilities including deaf-blindness I am aware that providing false information is an offence. Name of RMP:__________________ Medical Council registration number of RMP: ____________ Date of issuing the certificate: ____________ Place of issue: _________________. (Signature of RMP)