Yakutat COVID-19 Vaccine Form

Yakutat Community Health Center

The Yakutat Community Health Center is circulating this form to gather individual information from those who are interested in receiving a COVID vaccine. Please complete all questions and answer 'yes' to be added to the list. A YCHC health representative will contact you to schedule your appointment. Thank you!

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* 1. Last Name:

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* 2. First Name:

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* 3. Age:

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* 4. Are you a resident of Yakutat, Alaska? (Non-residents are still eligible for the vaccine).

Yes

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* 5. Are you Native American or Alaska Native?

Yes

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* 6. Are you interested in receiving a COVID vaccine? (Vaccines comprise of 2-doses that are delivered via injection, separated by 28 days).

Yes

Other (please specify):

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* 7. Do you work in a health care setting or provide direct services to clients inside their home (including primary caregivers and respite care providers for the elderly/disabled)?

Yes

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* 8. Are you a frontline EMS/Fire volunteer?

Yes

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* 9. Has a health care professional ever diagnosed you with any of the following?

Cancer

Type 1 diabetes

Type 2 diabetes

Asthma

Heart disease

Weakened or compromised immune system

Kidney disease

Autoimmune disorder, such as rheumatoid arthritis or Crohn's disease

Chronic lung disease, such as COPD or emphysema

High blood pressure

None of the above

Other (please specify)

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* 10. Do you have a known allergy to polyethylene glycol (PEG) or polysorbate?

Yes

I don't know

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* 11. Have you ever had an allergic reaction to a vaccine or other type of injection? If yes, please describe.

Yes (please specify)

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* 12. Do you work in any of the following areas where your job must be performed on-site and involve being in close proximity (6 feet or less) to the public or coworkers?

Education (teachers and other school staff, childcare worker and support staff, indigenous language and culture educators)

Public Safety (public safety officer, state trooper, office of children's services).

Food and Agriculture (seafood, food distributor)

Grocery Store workers

U.S. Postal Service workers

Public Transit workers (rural aviation in essential air services, rural cab service workers)

Utility and power workers

Water and wastewater workers

I do not work in any of these areas

My job requires me to be in close proximity to the public, but is not listed above (please specify):

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* 13. Day time contact number:

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* 14. Considering the unstable cellular service available in our community, if the contact number you provided is a mobile phone, do you give the YCHC permission to reach out via text? (No protected health information will ever be transmitted via SMS text message.)

Yes

My phone number is not a mobile

Yakutat COVID-19 Vaccine Form

Yakutat Community Health Center

Question Title

* 1. Last Name:

Question Title

* 2. First Name:

Question Title

* 3. Age:

Question Title

* 4. Are you a resident of Yakutat, Alaska? (Non-residents are still eligible for the vaccine).

Question Title

* 5. Are you Native American or Alaska Native?

Question Title

* 6. Are you interested in receiving a COVID vaccine? (Vaccines comprise of 2-doses that are delivered via injection, separated by 28 days).

Question Title

* 7. Do you work in a health care setting or provide direct services to clients inside their home (including primary caregivers and respite care providers for the elderly/disabled)?

Question Title

* 8. Are you a frontline EMS/Fire volunteer?

Question Title

* 9. Has a health care professional ever diagnosed you with any of the following?

Question Title

* 10. Do you have a known allergy to polyethylene glycol (PEG) or polysorbate?

Question Title

* 11. Have you ever had an allergic reaction to a vaccine or other type of injection? If﻿ yes, please describe.

Question Title

* 12. Do you work in any of the following areas where your job must be performed on-site and involve being in close proximity (6 feet or less) to the public or coworkers?

Question Title

* 13. Day time contact number:

Question Title

* 14. Considering the unstable cellular service available in our community, if the contact number you provided is a mobile phone, do you give the YCHC permission to reach out via text? (No protected health information will ever be transmitted via SMS text message.)

* 11. Have you ever had an allergic reaction to a vaccine or other type of injection? If yes, please describe.