MPX Vaccine Assessment

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Mpox Vaccine Assessment

Chester County Health Department

The Chester County Health Department is providing vaccinations to protect against mpox to individuals at high risk of exposure or serious illness.

Vaccination supply is currently limited and therefore require you to respond to assessment questions to determine your eligibility. The assessment includes demographic, medical history, and sexual activity related questions. All your responses are confidential and safely secured. The information you provide is used by Health Department staff to determine your eligibility. Completing the survey will not provide you an immediate determination of eligibility.

You are not guaranteed a vaccine by completing this assessment. Individuals will be contacted by the Health Department based on eligibility criteria and not based on the date you complete the questions.

If you are not immediately eligible, your information will be kept to potentially receive a vaccine in the future depending on your risk factors and available vaccines.

This form is HIPAA compliant, meaning your health information will be protected. Your personal information will be used to connect you to mpox vaccine.

Thank you for trusting us with your care.

If you have any questions about Mpox or vaccines/treatments, please call the Health Department at 610-344-6225 or go to the CDC Mpox information page.

Click "NEXT" to begin.

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Do you have a chronic medical condition?* This field is required.

Yes

No

3

Are you immunocompromised (have a medical condition that affects your immune system)?* This field is required.

Yes

No

4

Do you have atopic dermatitis or eczema?* This field is required.

Yes

No

5

How recently have you been sexually-active?* This field is required.

Within the last 2 weeks

Within the last 4 weeks

More than 4 weeks ago

Not active

6

How many sexual partners did you have in that time period?* This field is required.

1

2

3 or more

None/Not Applicable

7

How many of your sexual partners were anonymous?* This field is required.

1

2

3 or more

None/Not Applicable

8

Are you a sex worker?* This field is required.

Yes

No

9

Have you ever exchanged money or other goods/services for sex?* This field is required.

Yes

No

10

Are you experiencing homelessness or are you housing insecure?* This field is required.

Yes

No

11

How recently did you attend an event such as a rave, sex party, sauna/bathhouse, or other social venue?* This field is required.

Within the last 2 weeks

Within the last 4 weeks

More than 4 weeks ago

12

Are you planning to attend an event within the next month?* This field is required.

Yes

No

13

How recently did you meet sexual partners found though online apps or social media platforms?* This field is required.

Within the last 2 weeks

Within the last 4 weeks

More than 4 weeks ago

14

Are you planning on meeting someone in the next month?* This field is required.

Yes

No

15

Have you recently been diagnosed with an sexually transmitted infection such as gonorrhea, syphilis, chlamydia, or HIV?* This field is required.

Within the last 3 months

Within the last 6 months

Within the last 12 months

No diagnosis

16

Are you currently prescribed HIV pre-exposure prophylaxis (PrEP)?* This field is required.

Yes

No

17

Have you been in close contact (come in contact with someone's skin, mucous, or other bodily fluids) with someone experiencing symptoms such as a rash or sores in the past 2 weeks?* This field is required.

Yes

No

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Have you been in close contact (come in contact with someone's skin, mucous, or other bodily fluids) with someone who has been diagnosed with mpox within the last 2 weeks?* This field is required.

Yes

No

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Did you attend an event with individuals who have since been diagnosed with mpox?* This field is required.

Yes

No

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Do you have mpox symptoms which includes any rashes or lesions on your body?* This field is required.

Yes

No

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Do you otherwise know or suspect that you were exposed to mpox or another sexually transmitted infection in the last 14 days?* This field is required.

Yes

No

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Full Name* This field is required.

First Name

Last Name

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Email Address* This field is required.

example@example.com

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Phone Number* This field is required.

Please enter a valid phone number.

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What is your date of birth?* This field is required.

Date

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What is your sex assigned at birth?* This field is required.

Female

Male

Other

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Do you identify as transgender?* This field is required.

Yes

No

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Do you identify as non-binary or otherwise gender non-conforming?* This field is required.

Yes

No

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What is your sexuality?* This field is required.

Heterosexual

Homosexual

Bisexual and/or pansexual

Other

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Are you a woman who has sex with men who has sex with men?* This field is required.

Yes

No