🕷️ Crawler Inspector

Important Things to Note Please make sure that you meet the eligibility criteria before completing this form.      The information provided must be accurate as of the date of submission. Your application will be processed upon your submission of a complete set of documents.      If the Vaccinated Person is a minor aged below 21 years old, the application must be submitted by his/her parent or legal guardian.      If the Vaccinated Person is under disability or deceased, the application may be submitted by his/her next-of-kin, donee or deputy, or the executor or administrator of his/her estate.      The application must include the following:  a. Copy of NRIC/FIN (Front and Back) of:  (i) Vaccinated Person; and  (ii) Parent / Legal Guardian / Next-of-Kin / Donee / Deputy / Executor / Administrator (if application is on behalf of Vaccinated Person or his/her estate).    b. Request for Medical Information form, completed by the Vaccinated Person's primary attending doctor. The Request for Medical Information form may be downloaded from https://go.gov.sg/rmi-vifap .    c. For persons vaccinated with Sinovac-CoronaVac under the SAM Programme: Please submit a copy of the medical memo by the Vaccinated Person’s doctor, indicating the doctor’s assessment of unsuitability to receive the mRNA vaccines OR the proof of enrolment to the programme (e.g. SMS invitation). Part A1 - Personal Particulars of Vaccinated Person 1. Name (as in NRIC/FIN, in block letters) [“Vaccinated Person”]: 2. NRIC/FIN no. 3. Date of Birth No date selected 4. Ethnic Group Chinese Malay Indian Others 5. Residential Status Singapore Citizen Permanent Resident Long-Term Pass Holder Others 6. Mailing Address (Including Postal Code) (optional) Only if mailing address is different from NRIC 7. Mobile Number 8. Home Number (optional) 9. Email Address Part A2 - Personal Particulars of Person's Submitting on Vaccinated Person's Behalf Only applicable for applications submitted by a parent / legal guardian / next-of-kin / donee / deputy / executor / administrator on behalf of the Vaccinated Person or his/her estate. 10. Are you submitting this application on behalf of the Vaccinated Person? Part B: Information on COVID-19 Vaccination Information can be found on the Vaccination Card or Health Hub records. Please list all doses received. 11. Date of COVID-19 Vaccination Dose #1 No date selected 12. Vaccine Brand Pfizer-BioNTech Moderna Sinovac-CoronaVac Novavax 13. Place of Vaccination 14. Batch No. Batch No can be found on the Vaccination Card or Health Hub records 15. Vaccinated Arm (optional) Left Arm Right Arrm 16. Did you receive a second dose of the vaccine? Part C: Information on Serious Side Effect(s) 17. Date of Serious Side Effect No date selected 18. Hospitalisation Yes No hospitalisation 19. Medical Information on the Serious Side Effect(s) Please submit the Request for Medical Information form completed by the primary attending doctor of the Vaccinated Person. The form may be downloaded from https://go.gov.sg/rmi-vifap     If your doctor has provided you with other supporting medical documents, they may also be submitted.     If there are multiple documents, please zip them into one single file to attach to the application form.     [For Persons vaccinated with Sinovac-CoronaVac under the SAM Programme]: Please submit a copy of the medical memo by the Vaccinated Person’s doctor, indicating the doctor’s assessment of unsuitability to receive the mRNA vaccines OR the proof of enrolment to the programme (e.g. SMS invitation).    PDF, JPG, JPEG, zip files accepted 19. Medical Information on the Serious Side Effect(s) Click to upload file, maximum file size of 4 MB Maximum file size: 4 MB 20. Name of Medical Doctor 21. Place of Practice of Medical Doctor 22. Copy of NRIC/FIN (Front and Back) of Vaccinated Person Copy of NRIC/FIN (Front and Back) of the Next-of-Kin / Donee / Deputy / Administrator / Legal Guardian is also required if application is on behalf of Vaccinated Person.    If there are multiple documents, please zip them into one single file to attach to the application form.     PDF, JPG, JPEG, zip files accepted 22. Copy of NRIC/FIN (Front and Back) of Vaccinated Person Click to upload file, maximum file size of 1 MB Maximum file size: 1 MB Part D: Consent and Declaration I understand that the sharing of Personal Information I have given between different entities such as the Government, and certain statutory boards, and organisations as approved by the Government (collectively “Cooperating Parties”) will assist in the evaluation of the Vaccinated Person’s eligibility for the VIFAP. For the purposes of this form, Personal Information means an individual’s personal data (e.g. name, NRIC No./FIN, address, age, sex, family/household structure) or medical information, that is relevant for the purposes set out below.       By submitting this application, I hereby:  a. agree that any Cooperating Party may use or collect the information I have given for the purposes of:  (i) evaluating the eligibility of the Vaccinated Person for the VIFAP;  (ii) the administration and provision of the VIFAP; and/or   (iii) data analysis, evaluation and policy formulation, in which I and/or the Vaccinated Person shall not be identified as specific individuals or households; and  b. acknowledge that the Cooperating Parties may contact the Vaccinated Person’s primary attending doctor or medical care team regarding the medical information of the Vaccinated Person, for the purposes set out in (a)(i)-(iii) above.      I understand that this consent shall remain in effect unless revoked in writing. I accept that the withdrawal of consent will only take effect within 7 working days from the date of receipt of the written request for withdrawal.      This consent shall be governed by and construed in accordance with the laws of the Republic of Singapore.      I declare that I am making this application on my own behalf, or I am an individual authorised to provide consent on behalf of the Vaccinated Person.       Where I am providing consent on behalf of the Vaccinated Person who is under 21 years of age, I further declare that I am his/her parent or legal guardian.      Where I am providing consent on behalf of the Vaccinated Person who is under disability or deceased, I further declare that I am his/her next-of-kin, donee or deputy, or the executor or administrator of his/her estate.      Where I am providing consent on behalf of the Vaccinated Person who is mentally incapacitated, I further declare that I am:  a. his/her appointed donee(s) acting under a Lasting Power of Attorney granted by the Vaccinated Person under the Mental Capacity Act (Cap. 177A) when he/she was above 21 years old; or  b. his/her deputy(s) appointed by the Court under the Mental Capacity Act (Cap. 177A) to act on behalf of the Vaccinated Person.      I declare that the information I have given is accurate, true and complete. I understand that providing any misleading, inaccurate, untrue or incomplete information may invalidate this application and disqualify the Vaccinated Person from the VIFAP.      I have read the Terms and Conditions of Payment under the VIFAP and agree that any payment (if eligible) under the VIFAP to or for the benefit of the Vaccinated Person or his/her estate is subject to the Terms and Conditions of Payment under the VIFAP. 23. Declaration by Applicant I declare that I have read and understood the Consent and Declaration Clauses in Part D of the Application Form.