Vaccine Pop-up Site Screening Form

Moderna COVID-19 Booster Clinic
OCHD COVID-19 Moderna Booster-only vaccine clinic (PRIVATE CLINIC) Location: CC Basement Level Date: 4/22/22 \| Time: 10am to 12pm

The requested form is not available at this time.

1. Are you sick today?*
- Yes
- No
2. Have you been diagnosed with COVID-19 disease and are currently in isolation?*
- Yes
- No
3. Have you been exposed to someone with COVID- 19 disease and are currently in quarantine?*
- Yes
- No
4. Have you been treated with antibody therapy for COVID-19 in the last 90 days (3 months)?*
- Yes
- No
5. Do you have severe allergic reactions to any vaccine or shots in the past?*
- Yes
- No
Hidden
6. Are you currently eligible for the vaccine according to the NYS Phased Distribution Plan?*
- Yes
- No
6. Are you an FDA-approved age to receive the COVID-19 vaccine?*
- Yes
- No
Comments
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