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 immediately because we don't want you to make a trip to get your vaccine and then get turned away.

Please enter your name, email address, and the phone you are most likely to answer below IF you would like to be placed on a standby list if you don't currently qualify. IF we have vaccine remaining at the end of a vaccination day we may call even if you don't currently qualify to make sure no vaccine goes to waste.

First Name

Last Name

Best Number to Reach You

Email Address

Please Confirm Your Email Address

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

No

Have you ever had an allergic reaction to Polysorbate? *

Yes

No

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

Yes

No

Have you received ANY vaccine in the last 14 days? *

Yes

No

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

Yes

No

Have you been exposed to someone in the past 14 days that was currently positive for COVID-19? *

Yes

No

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

Yes

No