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

Registration and Pre-Screening for UITCT COVID Vaccine
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 COVID-19 VACCINE FROM UITCT, YOU MUST BE OVER THE AGE OF 12. The Moderna vaccine is administered in 2 doses, 28 days apart. The Pfizer vaccine is administered in 2 doses, 21 days apart. Vaccine received will be based on availability. A 3rd Dose COVID Booster is currently available to those who are moderate to severely immunocompromised, specifically, solid organ transplant recipients or those who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise.
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
COVID Vaccine Dose *

1st Dose 2nd Dose 3rd Dose (Booster)
Date of first dose.

Month Day Year
Date
Facility of first dose.
Vaccine Received
Date of second dose.

Month Day Year
Date
Facility of second dose.
Vaccine Received
The population of moderately and severely immunocompromised people who are currently eligible for COVID boosters included;
- Active treatment for solid tumor and hematologic malignancies
- Receipt of solid-organ transplant and taking immunosuppressive therapy
- Receipt of CAR-T-cell or hematopoietic stem cell transplant (within 2 years of transplantation or taking immunosuppression therapy)
- Moderate or severe primary immunodeficiency (e.g., DiGeorge, Wiskott-Aldrich syndromes)
- Advanced or untreated HIV infection
- Active treatment with high-dose corticosteroids (i.e., ≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, TNF blockers, and other biologic agents that are immunosuppressive or immunomodulatory.
If you qualify for the COVID booster and did not receive your previous doses at UITCT, you must bring proof of your first 2 vaccinations with you to your visit.
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 may not be eligible to receive the COVID-19 Vaccine at this time.

A member of our medical staff will review your case and you will be contacted regarding your eligibility. By submitting this form you agree to allow us to contact you directly by either phone or email regarding the COVID-19 vaccine.
YOU ARE ELIGIBLE TO REGISTER TO RECEIVE THE COVID 19 VACCINE FROM UITCT.

You will be contacted directly to schedule your appointment time.
Appointment

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