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.
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