OCFS-4411. Potassium Iodide-KI Refusal-Opt-Out Form

Form 4411, Potassium Iodide Refusal-Opt-Out Form, is a form used by the New York State Office of Children and Family Services (OCFS) for individuals to opt out of taking the Potassium Iodide (KI) tablets prescribed by the OCFS. The purpose of this form is for individuals to make a formal, written request to the OCFS to opt out of taking the KI tablets.

This form is typically used by individuals who are over 18 years of age and reside in the emergency planning zone of any nuclear power plant within New York State, as prescribed by the OCFS. It is also used by parents or legal guardians of minors who are in the same emergency planning zone.

The form consists of three sections or fields. The first section requires the individual to provide their full name, date of birth, address, and phone number. The second section requires the individual to provide the name of the nuclear power plant they reside near. The third section requires the individual to sign and date the form. Additionally, the form also includes a section for the signature of the parent or legal guardian of a minor.

Important fields in this form include the individual's full name, date of birth, address, phone number, and the name of the nuclear power plant they reside near. Specific instructions for completing the form include ensuring all three sections are completed and that all signatures are included. It is important to accurately complete this form because it serves as an official request for opting out of taking the KI tablets prescribed by the OCFS.

An example scenario where this form would be used is if an individual resides in the emergency planning zone of a nuclear power plant in New York State and wishes to opt out of taking the KI tablets prescribed by OCFS. The individual would then fill out this form, providing their full name, date of birth, address, phone number, and the name of the nuclear power plant they reside near. They would then sign and date the form. The purpose of using this form is to make a formal, written request to the OCFS to opt out of taking the KI tablets.

No additional documents are needed to complete this form. However, if the individual seeking to opt out of taking the KI tablets is a minor, the signature of their parent or legal guardian is also required on the form. There are no alternatives to this form for opting out of taking the KI tablets prescribed by the OCFS.