City of Evanston COVID Vaccination Contact Form

As the City continues to anticipate the availability of the COVID-19 vaccines, the Evanston Health and Human Services Department (EHHS) is asking you to complete this questionnaire in order to better understand our local vaccine demand and to plan accordingly. EHHS is following the phased approach to vaccination recommended by the Illinois Department of Public Health. While the vaccine supply is limited it is important to prioritize high risk individuals by working through the different phases.

This form is intended to be filled out by individuals who live or work in Evanston. By completing this form you are not registering for a vaccine but will be added to a list to receive updates on the vaccine process including registration for future vaccination clinics for each phase. For households with more than one individual, each person should complete the form separately

Vaccine will be made available to each eligible individual and no one will be denied based on race, gender, religion, economic and legal status. Please note that under the Emergency Use Authorization, the Pfizer vaccine is for individuals 16 years of age and older and the Moderna vaccine is for individuals 18 years of age and older.

This survey is HIPAA compliant, meaning your health information will be protected.

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* 1. Please provide the following contact information.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Age (years)

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* 3. Ethnicity

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* 4. Race

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* 5. Gender Identity

Male

Female

Transgender man/trans man/female-to-male (FTM)

Transgender woman/trans woman/male-to-female (MTF)

Genderqueer/gender non-conforming/neither exclusively male or female

Other

Decline to Answer

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* 6. Are you a healthcare worker? This population is defined by the CDC as "all paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infections materials."

Yes

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* 7. Are you in any of the FRONTLINE essential worker categories? This population is defined by the CDC as "workers who are in sectors essential to the functioning of society and are at substantially higher risk of exposure to SARS-CoV-2." (Please check all that apply)

First Responders (Firefighters Police)

Education (teachers, support staff, daycare)

Food & Agriculture

Manufacturing

Corrections workers

U.S. Postal service workers

Public transit workers

Other (please specify)

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* 8. Are you any of the "Other Essential Worker" categories? (Please check all that apply)

Transportation and logistics

Food Service

Shelter & Housing (construction)

Finance

IT & Communication

Energy

Media

Legal

Public Safety (Engineers)

Water & Wastewater

Other (please specify)

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* 9. Name of Work Organization

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* 10. Do you have an ID? (Any picture ID with your name will suffice)

Yes

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* 11. Do you have any of the following high risk medical conditions? (Please check all that apply)

Cancer

Chronic kidney disease

Chronic lung disease

Down Syndrome

Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies

Immunocompromised state (weakened immune system) from solid organ transplant

Very overweight or obese

Pregnancy

SIckle cell disease

Smoking

Type 2 diabetes mellitus

Other (please specify)

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* 12. Do you plan to receive the COVID-19 vaccination when it is available to you?

Yes

Unsure

City of Evanston COVID Vaccination Contact Form

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* 1. Please provide the following contact information.

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* 2. Age (years)

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* 3. Ethnicity

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* 4. Race

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* 5. Gender Identity

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* 6. Are you a healthcare worker? This population is defined by the CDC as "all paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infections materials."

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* 7. Are you in any of the FRONTLINE essential worker categories? This population is defined by the CDC as "workers who are in sectors essential to the functioning of society and are at substantially higher risk of exposure to SARS-CoV-2." (Please check all that apply)

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* 8. Are you any of the "Other Essential Worker" categories? (Please check all that apply)

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* 9. Name of Work Organization

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* 10. Do you have an ID? (Any picture ID with your name will suffice)

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* 11. Do you have any of the following high risk medical conditions? (Please check all that apply)

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* 12. Do you plan to receive the COVID-19 vaccination when it is available to you?

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* 13. Comments