The COVID-19 Vaccine is slowly becoming available to all Alaskans.  The Alaska Vaccine Allocation Committee will determine the groups of people who should receive the vaccine as supplies are limited for several months.  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.  

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* 1. Are you a full or part time resident of Petersburg Borough?

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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. Please the select the best answer based on your occupation

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* 10. 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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* 11. Please provide other information that you feel would assist us in scheduling you for a COVID-19 vaccine.  

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

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

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

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

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

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

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

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