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? *

Yes

Have you ever had an allergic reaction to Polysorbate? *

Yes

Have you ever had an allergic reaction to the COVID-19 vaccine? *

Yes

Have you tested positive for COVID in the past 14 days? *

Yes

Have you been EXPOSED to COVID in the past 14 days? *

Yes

Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *

Yes

Your age? *

Which of the following apply to you? (Please check all that apply.) *

Been receiving active cancer treatment for tumors or cancers of the blood

Received an organ transplant and are taking medicine to suppress the immune system

Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system

Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)

Advanced or untreated HIV infection

Active treatment with high-dose corticosteroids or other drugs that may suppress your immune response

NONE of the above