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COVID-19 Recipient Vaccination Questionnaire

  1. DHHSlogo

  2. COVID-19 Recipient Vaccination Questionnaire


    Please fill out ALL the information below


  5. Are you responsible for caring/cleaning in areas with COVID Patients?*

  6. Are you responsible for performing tasks with high risk of aerosolization (intubation, bronchoscopy, suctioning, invasive dental procedures, invasive specimen collection, CPR)?*

  7. Are you responsible for handling decedents with COVID?*

  8. Are you planning to be responsible for administration of the Vaccine?*

  9. What is the type of organization listed above? (Please Select One):*

  10. Do you work or reside in the organization listed above?*

  11. If you do not have an email/do not wish to disclose your email information, leave this blank and check the box below.

  12. Do Not Have/Do Not Wish To Disclose Email

  13. Communication Preference*

  14. Race

  15. Ethnicity

  16. Gender

  17. Are you an Essential Frontline Worker (Police, Food Processing, Teachers, etc.)?*

  18. Do you reside or work in a long-term care/assisted living facility?*

  19. Are you a member of a state or federal recognized tribal nation?*


  21. Review the below list of conditions known to increase risk of severe illness to COVID-19:

    • Asthma • Cancer • Cerebrovascular Disease • Chronic Obstructive Pulmonary Disease • Chronic Kidney Disease • Cystic Fibrosis • Hypertension or High Blood Pressure • Type 1 Diabetes Mellitus • Type 2 Diabetes • Immunocompromised from solid organ transplant • Immunocompromised state (weakened immune system) • Liver Disease • Neurologic conditions, such as Dementia • Obesity • Overweight (BMI > 25 kg/m2, but < 30 kg/m2) • Pregnancy • Pulmonary Fibrosis (having damaged or scarred lung tissues) • Sickle Cell Disease • Smoker • Thalassemia (a type of blood disorder) •

  22. How many conditions known to increase risk of severe illness from COVID-19 do you have?*

  23. CONSENT*

    (a) at least 18 years of age (b) the parent or legal guardian of the minor patient; or (c) the legal guardian of the patient. Further, I hereby give my consent to the licensed healthcare provider administering the vaccine, as applicable(each an “applicable Provider”), to share my personal, demographic and health condition information in order to provide me with vaccination services for the COVID-19 vaccine. I understand that the health data shared within this questionnaire will be used to determine my eligibility for receiving the COVID-19 vaccination and further determine timing of when the vaccine will be made available to me.

  24. DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

  25. Leave This Blank:

  26. This field is not part of the form submission.