Toggle navigation
English
አማርኛ
Tiếng Việt
한국어
Français
中文(台灣)
Español
English
Staff Sign In
This questionnaire is designed to gather information regarding your readiness for COVID-19 vaccination, and offer guidance and instruction to ensure your safety.
Are you a District Resident or Work in the District of Columbia?
District Resident
Work in the District
Neither
Work-related Information
Are you required to report in to work in Person?
No
Yes
Do you work in one of the following settings?
Healthcare (to include Veterinary Care)
Grocery Store
Food Packaging and Distribution
Manufacturing
Health, Human, or Social Services
K-12 Education
Child Care
Environmental Services
Commercial and Residential Property Maintenance / Management
Law Enforcement/Public Safety
Correctional Facility/Detention Center
Courts and Legal Services
Food Service
Public (Mass) Transit
US Postal Service
Local Government Agency
Federal Government Agency
Non-Public Transit Transportation Services (i.e. For-Hire Vehicles such as Taxi, Uber, Lyft)
Logistics/Delivery Services (i.e. UPS, FedEx)
Construction
Institution of Higher Education (i.e. colleges, universities, trade schools)
Information Technology
Media and Mass Communications
Public Works and Public Utilities
Not Eligible
No, I do not
Employer Information
Employer Name
Employer Address
Employer City
Employer State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Employer Zip Code
If you selected any of the above work settings, you must bring verification to your appointment (work ID badge, letter from your employer, copy of provider license, pay stub or other means of verification).
Medical & Preference Information
Have you had any severe reaction to a vaccine before?
Have you had any severe reaction to a vaccine before?
No
Have you had any severe reaction to a vaccine before?
Yes
Will this be your first COVID-19 vaccine dose?
Will this be your first COVID-19 vaccine dose?
No
Will this be your first COVID-19 vaccine dose?
Yes
Have you been diagnosed with one of the following medical conditions by your healthcare provider?
Asthma
Chronic Obstructive Pulmonary Disease (COPD), and other Chronic Lung Disease
Bone Marrow and Solid Organ Transplantation
Cancer
Cerebrovascular Disease
Chronic Kidney Disease
Congenital Heart Disease
Diabetes Mellitus
Heart Conditions, such as Heart Failure, Coronary Artery Disease, or Cardiomyopathies
HIV
Hypertension
Immunocompromised State
Inherited Metabolic Disorders
Intellectual and Developmental Disabilities
Liver Disease
Neurologic Conditions
Obesity, BMI ≥ 30 kg/m2
Pregnancy
Severe Genetic Disorders
Sickle Cell Disease
Thalassemia
No
Yes
Internal Session Id
