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Newport News COVID-19 Vaccine Clinic Feb. 3, 2021
Host Site: The Freeman Center at Christopher Newport University
COVID 19 Pre-Vaccination Screening Questionnaire
These questions are used to determine eligibility to recieve the vaccination. If you can answer "yes" to any of these questions, you do not meet the criteria to schedule an appointment at the Newport News COVID-19 Vaccine Clinic at this time.
Name
*
First Name
Last Name
Do you have the COVID-19 disease currently?
*
Yes
No
Have you received any other vaccine in the last 14 days?
*
Yes
No
Have you received COVID 19 monoclonal antibody or convalescent plasma treatment in the last 90 days?
*
Yes
No
Do have an allergy to any components of the COVID 19 vaccine?
*
Yes
No
Are you currently in quarantine due to a possible or confirmed COVID exposure?
Yes
No
COVID-19 Pre Vaccination Screening Questionnaire
If you answer "yes" to the any of the following set of questions, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked at the time of vaccination.
Are you pregnant or do you plan to become pregnant?
*
Yes
No
Are you breastfeeding?
*
Yes
No
Have you had a positive COVID-19 test
*
Yes
No
I don't know
Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something for example, reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?
*
Yes
No
Do you have a bleeding disorder or are you taking a blood thinner?
*
Yes
No
Are you immunocompromised or do you take a medicine that affects your immune system?
*
Yes
No
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Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Race
*
American Indian/Alaskan Native
Asian
Black or African American
Hawaiian Native or Other Pacific Islander
White
Not Stated
Hispanic/Latino
*
Yes
No
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Is the above phone number a cell phone?
*
Yes
No
I elect to recieve vaccination information or reminders by
*
Text
Email
Source or Agency employed with:
*
Please Select
City of Newport News
Newport News Public Schools
York County
York County Public Schools
Christopher Newport University
TPMG Patient
K-12 Private
Federal
State Employee
Job Title
*
Back
Next
Appointment Selection
Registration Code-This code was provided by your point of contact. You will not be able to submit your registration without the code.
Appointment
*
The above information is true to the best of my knowledge. I agree to recieve he COVID-19 vaccination
*
Yes
I am agreeing to recieve the COVID-19 Vaccination, and understand i will be provided with all relevant safety materials, and have the ability to ask questions. Please type in your full name if you agree with the above statement
*
Submit
Should be Empty: