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!

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.)

0 of 14 answered
 

T