COE Employee COVID Vaccination Contact Form

This form is intended to be filled out by individuals who are employed by the City of Evanston. By completing this form you are not registering for a vaccine but will be added to a list to receive registration for future vaccination clinics.

Vaccine will be made available to each eligible individual and no one will be denied based on race, gender, religion, economic and legal status. Please note that under the Emergency Use Authorization, the Pfizer vaccine is for individuals 16 years of age and older and the Moderna vaccine is for individuals 18 years of age and older.

This survey is HIPAA compliant, meaning your health information will be protected.

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* 1. Please provide the following contact information.

Name

COE Department

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Age (years)

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* 3. Ethnicity

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* 4. Race

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* 5. Gender Identity

Male

Female

Transgender man/trans man/female-to-male (FTM)

Transgender woman/trans woman/male-to-female (MTF)

Genderqueer/gender non-conforming/neither exclusively male or female

Other

Decline to Answer

COE Employee COVID Vaccination Contact Form

Question Title

* 1. Please provide the following contact information.

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* 2. Age (years)

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* 3. Ethnicity

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* 4. Race

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* 5. Gender Identity

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* 6. Comments