LCDHE Monkeypox vaccine interest and eligibility form

En Español: https://hipaa.jotform.com/222354806663155

Recent cases of monkeypox have been identified in Colorado.

Some people who may have been recently exposed to monkeypox are recommended to receive the Jynneos vaccine. This vaccine has been fully approved by the FDA for the prevention of monkeypox in people aged 18 years and older AND for individuals less than 18 years of age determined to be at high risk for monkeypox infection, with signed parental consent.

Getting vaccinated after a recent exposure lowers the chance of getting monkeypox. The sooner an exposed person gets the vaccine, the better. The vaccine can also reduce severity of symptoms if you do develop a monkeypox infection. Data shows that receiving the first dose of Jynneos vaccine offers early protection against monkeypox.

How to get vaccinated: Vaccination will be available through the Larimer County Department of Health and Environment. If you think you may be eligible for the vaccine, complete the following form. Vaccine clinics are held frequently and you will be contacted soon after completing this form to make an appointment, if eligible.

If you would rather determine eligibility and make an appointment over the phone, please call 970-498-6700.

If you are unsure if you should receive the Jynneos vaccine for monkeypox, you can find more information at the LCDHE webpage: www.larimer.gov/monkeypox

NOTE: Coloradans who self-attest to being immunocompromised are still eligible to receive a second dose four weeks after their first to ensure they achieve maximum protection.

The Larimer County Department of Health and Environment takes patient privacy very seriously. Responses to this form will be kept confidential.

If you are eligible, you will be able to register for a vaccine clinic, pending vaccine availability. You will be contacted by staff from Larimer County Department of Health and Environment (LCDHE) soon after completing this form regarding appointment registration. You will not receive the vaccine without a scheduled appointment. If you would rather determine eligibility and make an appointment over the phone, please call 970-498-6700

People who can receive the vaccine include:

Jynneos vaccines are available at many locations in Colorado, and there are no longer specific eligibility criteria for mpox vaccination - anyone who thinks they may be at risk of exposure to mpox can get vaccinated. Public health specifically recommends vaccination for people who may be at higher risk based on data from recent outbreaks, including:
- Anyone who has had close physical contact with someone who has mpox in the last 14 days.
- Anyone who:
  - Has multiple or anonymous sexual partners, or
  - Has close physical contact with other people in a venue where anonymous or group sex may occur, or
  - Was diagnosed with gonorrhea or syphilis in the past six months, or
  - Is living with HIV, or
  - Is immunocompromised and anticipates potential mpox exposure, or
  - Already uses or is eligible for HIV PrEP (medication to prevent HIV, e.g. Truvada or Descovy or Apretude), or
  - Has sex in exchange for money, shelter, food, and other goods or needs.
- Anyone identified by public health as a known high-risk contact of someone who has mpox.
- Anyone whose sexual partner identifies with any of the above scenarios.
- Anyone who anticipates experiencing any of the above scenarios.

Note: People who currently have a fever, rash, or sores that may be due to monkeypox cannot get vaccinated. Instead, they should separate from others and contact a health care provider to get tested. Treatment may be an option. More information can be found on the LCDHE Monkeypox webpage: www.larimer.gov/monkeypox

Have you or your sexual partner been in close contact with a person who has received a positive test result for mpox (monkeypox)?*

YesNo

Do you currently have fever (temperature of 100.4° F [38° C] or more, or feeling hot if a thermometer is not available) or a rash (rash can look like pimples or blisters that appears on the face, inside the mouth, and on other parts of the body, like the hands, feet, chest, genitals, or anus) that developed in the past 14 days?*

YesNo

Have you or your sexual partner been in close contact with a person who thinks they have mpox (monkeypox) or has symptoms of mpox (including rash, swollen lymph nodes, fever, headache, muscle aches, joint pain, and back pain)?*

YesNo

Do you believe that you or your partner may be at risk of exposure to mpox now or in the future?*

YesNo

Are you under the age of 15? ** NOTE: Parent or legal guardian signed consent is required for all mpox vaccines administered to those under 18 years of age.*

YesNo

Please provide the following information so that you can request a vaccine appointment. All information provided is confidential and will only be used to request your appointment.

Full Name*

First NameLast Name

Date of Birth*

Date

E-mail*

example@example.com

Phone Number*

Were you referred to fill out this form by an agency or healthcare provider?*

YesNo

Please indicate the provider or agency that referred you to fill out this form below: *

Is there anything else you would like for us to know about your situation?

Please indicate the date of last exposure (the most recent date you were in close contact with the individual who tested positive):

Date

Have you or your sexual partner had multiple and/or anonymous sex partners or had close physical contact with other people in a venue where anonymous or group sex may occur?*

YesNo

Please select all that apply. Have/are you:*

Been diagnosed with one or more sexually transmitted infections (e.g. chlamydia, gonorrhea, syphilis) in the past 6 monthsLiving with HIVHad more than one sex partner in the past 6 monthsAlready using or eligible for HIV PrEP (Medication to prevent HIV such as Truvada, Descovy, or Apretude)Engaging in commercial and/or transactional sex (e.g. sex in exchange for money, shelter, food, and other goods or needs)Someone whose sexual partner identifies with any of the above scenariosNot Applicable / None of the AboveSomeone who has had more than one sex partner

Have you been diagnosed with a bacterial sexually transmitted infection (e.g. chlamydia, gonorrhea, syphilis) in the past 6 months?*

YesNo

Do you have a history of inconsistent or no condom use with sexual partners(s)?

YesNo

Are you already using HIV PrEP (medication to prevent HIV, e.g. Truvada or Descovy or Apretude)?

YesNo

Are you living with HIV and considered vulnerable to monkeypox exposure?

YesNo

Are you working in the sex worker industry; exchanging sex for money or goods?

YesNo

Are you a person experiencing homelessness (PEH) with high-risk behaviors?

YesNo

LCDHE Mpox (monkeypox) vaccine interest form

Please answer the following questions to request a vaccination: