Vaccinia Information and Forms

Introduction of New Forms and Information

ROHP is making available more of its medical forms and information programs on its website. You will continue to see more information added to the ROHP library over time.

How do I access these new forms and information?

These forms and information can be downloaded from the ROHP website by clicking on any of the titles and saved on your local hard drive or other storage device. When completed, the form(s) should be sent to ROHP either by email to or faxed to the ROHP secure electronic fax number 617-977-8788.

 Vaccinia Virus Vaccination Information Program

The vaccinia vaccination information program provides research, laboratory and animal care personnel authorized and medically cleared to receive the vaccine with an outline of the process, roles and responsibilities, benefits and risks, and post-vaccination expectations that should be considered prior to any voluntary consent or declination of the vaccine.


Vaccinia Virus Vaccination Authorization
This authorization form is to be completed by Principal Investigators as part of the research protocol review and approval process of the Institutional Biosafety Committee. The form identifies the type of vaccinia strain used and the research, laboratory and animal care personnel with potential exposure to the vaccinia virus. Before the vaccine is offered, each person must be medically reviewed by ROHP to determine if any contraindications to the vaccine exist.  ROHP will provide a consultation on the vaccine as well. The vaccine is voluntary and is available to these personnel at no cost. If no contraindications are determined, each individual must provide written consent or declination of the vaccine.

Vaccinia Virus Vaccination Medical Review

This medical review form should be completed by each personnel included by the Principal Investigator on the Vaccinia Virus Vaccination Authorization Form. The completed form can be submitted to ROHP using the electronic instructions provided above or brought to ROHP at the time of their appointment. The review is conducted by an ROHP medical provider and includes a consultation to explain the benefits and risks of vaccination. If the review indicates contraindications to the vaccinia vaccine exist, the vaccine will not be offered at that time.