Yakutat COVID-19 Vaccine Form

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!
1.Last Name:(Required.)
2.First Name:(Required.)
3.Age:(Required.)
4.Are you a resident of Yakutat, Alaska? (Non-residents are still eligible for the vaccine).(Required.)
5.Are you Native American or Alaska Native?(Required.)
6.Are you interested in receiving a COVID vaccine? (Vaccines comprise of 2-doses that are delivered via injection, separated by 28 days).(Required.)
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)?(Required.)
8.Are you a frontline EMS/Fire volunteer?(Required.)
9.Has a health care professional ever diagnosed you with any of the following?(Required.)
10.Do you have a known allergy to polyethylene glycol (PEG) or polysorbate?(Required.)
11.Have you ever had an allergic reaction to a vaccine or other type of injection? If yes, please describe.(Required.)
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?(Required.)
13.Day time contact number:(Required.)
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.)(Required.)
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