Phase & Initial Qualification Questionnaire

Welcome to our COVID vaccine enrollment process!!
 
These first few questions are health qualifications that can definitely disqualify you from receiving the vaccine.  You may have to answer these again in your consent form.
 
We ask you these questions first because we don't want you to make a trip to get your vaccine and then get turned away.
Have ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures? *
Have you ever had an allergic reaction to Polysorbate? *
Have you ever had an allergic reaction to the COVID-19 vaccine? *
Have you tested positive for COVID in the past 14 days? *
Have you been EXPOSED to COVID in the past 14 days? *
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *
Are you signing up for your third dose? *
Which of the following apply to you? (Please check all that apply.) *