Monkeypox Vaccine Eligibility Form
IMPORTANT NOTICE: Currently, Montana's supply of the Monkeypox vaccine is limited. At this time, the vaccine is only available for individuals who are at higher risk for Monkeypox. Based on your eligibility, you will be placed on our prioritized waitlist and will receive a phone call to schedule an appointment. Please note: submitting this form does not guarantee that you will be contacted for an appointment. If you do not meet eligibility requirements, you will be removed from this list and will not receive a follow-up call. If you are experiencing any symptoms of monkeypox, please isolate at home and contact your healthcare provider immediately.
I have read the above notice.
Date of Birth
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County of Residence
Due to limited supply, monkeypox vaccine is only available for individuals at high risk. Of the following categories, please select the one(s) that apply to you.
I have had exposure to individual(s) with confirmed orthopoxvirus/monkeypox virus infection.
I meet one or more of the following criteria: Individuals that are identified through case investigations/contact tracing, individuals who are aware that one of their sexual partners from the past 2 weeks has received a monkeypox diagnosis, and individuals that report group sex/sex with multiple partners in the past two weeks in association with certain events, venues, or geographical areas in which monkeypox transmission has been reported.
I am a healthcare or public health response team member that has been designated by public health authority to be vaccinated for preparedness purposes according to ACIP guidance. (NOTE: At this time, most clinicians in the US and laboratorians not performing the orthopox generic test to diagnose orthopox viruses, including Monkeypox virus, are not advised to receive monkeypox vaccine.)
I am an individual aged 18+ who meets any of the following criteria: Individuals who have recently had multiple or anonymous sexual partners; OR Partners of individuals who have had multiple or anonymous sexual partners; OR Sex workers (of any sex); OR Staff (of any sex) at establishments where sexual activity occurs (e.g., bathhouses, saunas, sex clubs). OR Individuals who were diagnosed with gonorrhea or early syphilis within the past 12 months; OR persons experiencing homelessness with high-risk behaviors; OR are on HIV pre-exposure prophylaxis; OR are part of high risk cohorts identified by clinical staff in the correctional system; OR individuals deemed to have high-risk based on individual risk assessments.
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