COVID19 Screening Questionnaire
Email address *
First Name *
Last Name *
Are you in the 1a vaccination group? *
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Are you in the 1b or 1c vaccine group? *
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Address *
City *
State *
Zip Code
Mobile phone number (123-456-7890)
Race *
Ethnicity *
Fever of feeling ill today? *
History of severe allergic reaction (e.g., anaphylaxis) to any component of this vaccine? *
History of severe allergic reaction to another vaccine? *
History of severe allergic reaction (e.g., anapylaxis) to an injectable therapy? *
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *
Have you received another vaccine in the last 14 days? *
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? *
Are you pregnant or breastfeeding? *
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