The COVID-19 Vaccine is now available to all Alaskans aged 12 and older and to non residents that work in Alaska. This survey will help PMC schedule people in a fair and safe manner.  This survey is HIPAA compliant and your personal information is needed to put you on a waiting list.    

We recommend getting the first vaccine that is available.  There are three vaccines currently available, while we cannot guarantee a specific type, if you do have a preference, please indicate in question 11.  

If you received your first dose of Moderna or Pfizer outside of Petersburg, we will need to see your shot record to provide dose #2.  While we will make every attempt to provide a second dose on time, a delay of up to 6 weeks is acceptable per CDC.  

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* 1. Is this survey for someone who is 17 years or younger?

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* 2. Last Name

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* 3. First Name

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* 4. What is your date of birth?  (MM/DD/YYYY)

Date

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* 5. Day Phone Number:

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* 6. Mobile Phone Number:

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* 7. Email address: 

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* 8. What is your preferred way of contact?

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* 9. Do you have any medical conditions that you feel would place you at greater risk for serious COVID-19 infections?

Examples: diabetes, Lung disease, heart disease, kidney disease, liver disease, high blood pressure, autoimmune condition, thyroid disease, cancer not in remission, obesity, etc.

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* 10. Provide other information that you feel would assist us in scheduling you for your COVID-19 vaccine such as planned out of town travel.   If you are filling this survey out for a minor, please indicate your name, relationship to minor and your contact info.

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* 11. Do you have any allergies, such as to medications, food, or vaccine components?

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* 12. Have you ever had a serious reaction to a vaccine or any injectable?

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* 13. Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?

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

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* 15. Do you have cancer, leukemia, HIV/AIDs or other immune system problem?

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* 16. Do you have a bleeding disorder or are you taking a blood thinner?

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* 17. Have you received any other vaccines in the past 14 days?

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* 18. For women: Are you pregnant or could become pregnant in the next month or currently breastfeeding?  

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* 19. Would you like information or instructions in your native language?  

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