Clinic (E) Registration and Pre-Screening for COVID Vaccine 01.2021

Registration and Pre-Screening for UITCT COVID Vaccine
Please note that the current vaccine availability of the Moderna COVID-19 vaccine is limited. This form will be used for initial registration and pre-screening for vaccination eligibility at UITCT. UITCT is following IHS, CDC, and state guidelines for the administration of the vaccine. Registrants will be contacted with the next steps to schedule a vaccine appointment based on selected availability. It is important that you double-check the contact information in this section so that we will be able to reach you.

TO BE ELIGIBLE TO RECEIVE THE VACCINE FROM UITCT, YOU MUST MEET THE FOLLOWING CRITERIA:
- You are an active patient at UITCT (Seen within the last 3 years) over the age of 18; or
- You are an American Indian/Alaska Native enrolled in a Federally or State Recognized Tribe with Tribal Documentation over the age of 18; or
- You are an adult Non-Native household member an American Indian/ Alaskan Native.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Residence *
Phone Number *
Please enter a valid phone number.
Email
example@example.com
Gender *

Female Male Decline to Specify Other
Ethnicity *

Hispanic or Latino Not Hispanic or Latino Unknown / Not Reported
Race *

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Unknown / Not Reported
Tribe of Membership
Moderna COVID Dose *

1st Dose 2nd Dose
Date of first dose.

Month Day Year
Date
Facility of first dose.
Have you been seen for a medical visit at the UITCT clinic within the past 3 years? *

Yes No
Are you an American Indian/Alaska Native enrolled in a Federally or State Recognized Tribe with Tribal Documentation?

Yes No
Are you an adult Non-Native household member an American Indian/ Alaskan Native.

Yes No
Name of American Indian/ Alaskan Native Household Member:
Date of Birth of American Indian/ Alaskan Native Household Member:

Month Day Year
Date
Do you have any of the following chronic medical conditions? (Information provided is subject to verification by UITCT medical clinic records)

Cancer Chronic Kidney Disease (Stage 1-5, including dialysis patients) COPD (Chronic Obstructive Pulmonary Disease) Diabetes Heart condition, such as CHF (congestive heart failure), coronary artery disease,history of heart attack or cardiomyopathies History of Solid-Organ Transplant Obesity (BMI>30 kg/m2) Sickle Cell Disease Other Chronic Medical Condition None of the Above
Please Specify Other Chronic Medical Condition:
Have you had any other vaccine in the past 2 weeks (flu, pneumonia, shingles, etc.)? *

Yes No
Have you been exposed or tested positive for COVID-19 within the past 14 days? *

Yes No
Are you pregnant? *

Yes No
You are currently not eligable to receive the COVID-19 Vaccine From UITCT.

By submitting this form you agree to allow us to contact you directly by email when the COVID-19 vaccine becomes more widely available. You can also check back at www.uitct.org for updates on vaccine availability.
YOU ARE ELIGIBLE TO REGISTER TO RECEIVE THE COVID 19 VACCINE FROM UITCT.

You will be contacted directly within the next 3 buisness days to schedule your appointment time.
Appointment
*The Moderna COVID 19 vaccine is 2 doses spaced 28 days apart. Please keep in mind while scheduling that you will need to return for your second dose in 28 days.

Please select ALL possible times that you would be available to come to the UITCT clinic for COVID 19 vaccination. You will be contacted directly within the next 3 business days to confirm an appointment time.

AM (9:00-12:00)

PM (1:00-4:00)

Wednesday, 2/3/2021

Monday, 2/8/2021

Tuesday, 2/9/2021

Friday, 2/12/2021

Tuesday, 2/16/2021

Please upload a copy of your Photo I.D *

Cancel of
Driver License Number
Expiration Date

Month Day Year
Date
State
Please upload a copy o your CDIB or Tribal Card

Cancel of
Should be Empty:

Registration and Pre-Screening for UITCT COVID Vaccine