English Español العربية አማርኛ
Please enter the information below if you are interested in receiving the monkeypox vaccine and either you can’t find an open spot right now, or you are not currently eligible. You are not guaranteed a vaccine by filling out this form.
If you are eligible or become eligible, Alexandria Health Department will contact you via email, text message, or phone call when vaccine appointments are available.
Vaccine will be made available to each individual based on eligibility factors and no one will be denied a vaccine based on race, gender, gender identity, sexual orientation, religion, economic, or citizenship status. This survey is HIPAA compliant, meaning your personal and health information is protected and kept confidential. If you are not currently eligible, we will email you if the Virginia Department of Health changes the eligibility requirements.
Once you submit this form you will get a confirmation email that we have received your information. You do not need to fill out this form more than once.
For more information on monkeypox, please visit alexandriava.gov/monkeypox.
Ingrese la información a continuación si está interesado en recibir la vacuna contra la viruela del mono. Completar este formulario no garantiza que recibirá una vacuna. Actualmente, el suministro de vacunas es limitado. Si es elegible y hay suficiente suministro de vacunas, el Departamento de Salud de Alexandria se comunicará con usted por mensaje de texto o por teléfono cuando haya citas disponibles para recibir la vacuna. Estamos utilizando la guía de elegibilidad actual del Departamento de Salud de Virginia para determinar la elegibilidad para recibir la vacuna contra la viruela del mono. Debe ser residente de Virginia para recibir esta vacuna en Virginia. Si vive en otro estado, consulte con su departamento de salud local. La vacuna se pondrá a disposición de cada persona elegible en función de los factores de riesgo, y a nadie se le negará una vacuna por motivos de raza, género, identidad de género, orientación sexual, religión, situación económica o ciudadanía. Este documento cumple con la ley Ley de Transferencia y Responsabilidad de Seguro Médico (Health Insurance Portability and Accountability Act, HIPAA), lo que significa que su información personal y médica está protegida y se mantiene confidencial. Una vez que envíe este formulario, recibirá un correo electrónico de confirmación indicándole que hemos recibido su información. No es necesario que complete este formulario más de una vez. Para obtener más información sobre la viruela del mono, visite alexandriava.gov/monkeypox .
يرُجى إدخال المعلومات أدناه إذا كنت مهتمًا بتلقي لقاح جدري القرود. لا نضمن لك الحصول على لقاح بملء هذا النموذج. فكميات اللقاح محدودة حالياً. إذا كنت مؤهلا لتلقي اللقاح، وكانت هناك كميات كافية منه، فستتصل بك إدارة الصحة في الإسكندرية عن طريق رسالة نصية أو مكالمة هاتفية عند توفر مواعيد تلقي اللقاح. نستخدم إرشادات الأهلية الحالية الصادرة عن إدارة الصحة بولاية فرجينيا لتحديد أهلية الحصول على لقاح جدري القرود. يجب أن تكون مقيمًا في ولاية فرجينيا لتلقي هذا اللقاح فيها. إذا كنت تعيش في ولاية أخرى، فيُرجى الرجوع إلى إدارة الصحة المحلية لديك. سيتم توفير اللقاح لكل فرد مؤهل بناءً على عوامل الخطر، ولن يتم حرمان أي شخص من اللقاح بناءً على العِرق أو الجنس أو الهوية الجنسية أو التوجه الجنسي أو الديانة أو الحالة الاقتصادية أو حالة المواطنة. هذا الأمر متوافق مع قانون إخضاع التأمين الصحي لقابلية النقل والمساءلة HIPAA( (، مما يعني أن معلوماتك الشخصية والصحية ستحظى بالحماية والسرية. بمجرد إرسال هذا النموذج، ستتلقى رسالة تأكيد بالبريد الإلكتروني تفيد بأننا تلقينا معلوماتك. لستَ بحاجة إلى ملء هذا النموذج أكثر من مرة. لمزيد من المعلومات حول جدري القرود، يُرجى زيارة .alexandriava.gov/monkeypox
የዝንጀሮ ፈንጣጣ ክትባትየመውሰድ ፍላጎት ካለዎት እባክዎ ከታች መረጃ ያስገቡ። ይህንን ቅጽ በመሙላትዎ ብቻ ክትባት ስለማግኘትዎ ዋስትና
አይሰጥዎትም። በአሁን ጊዜ የክትባት አቅርቦት የተወሰነ ነው።
ብቁ ከሆኑ፣ እና በቂ የክትባት አቅርቦት ካለ፣ የአሌክሳንድሪያ ጤና መምሪያ የክትባት ቀጠሮዎች በሚኖሩበት ጊዜ በጽሁፍ መልዕክት፣ ወይም በስልክ
ጥሪ ያገኝዎታል። የዝንጀሮ ፈንጣጣ ክትባት ብቁነትን ለመወሰን በአሁኑ ጊዜ የቨርጂኒያ ጤና መምሪያን የብቁነት መመሪያን እየተጠቀምን ነው።
ይህንን ክትባት በቨርጂኒያ ለመውሰድ የቨርጂኒያ ነዋሪ መሆን አለብዎት። በሌላ ግዛት የሚኖሩ ከሆነ፣ እባክዎ የአካባቢዎን የጤና መምሪያ ያነጋግሩ።
ክትባቱ ለእያንዳንዱ ግለሰብ የሚቀርበው በአደጋ ተጋላጭነት ላይ በመመስረት ነው እና ማንም ሰው በዘር፣ በጾታ፣ በጾታ መለያ፣ በወሲብ ዝንባሌ፣
በሃይማኖት፣ በኢኮኖሚ ወይም የዜግነት ሁኔታ ክትባት አይከለከልም። ይህ HIPAAን ደንብ ያከብራል፣ ማለትም ግላዊ እና የጤና መረጃዎ የተጠበቀ እና
ሚስጥራዊ ሆኖ የሚያዝ ነው።
አንድ ጊዜ ይህንን ቅጽ ካስገቡ መረጃዎን መቀበላችንን የሚያረጋግጥ ኢሜይል ይደርስዎታል። ይህንን ቅጽ ከአንድ ጊዜ በላይ መሙላት
አይጠበቅብዎትም።
ለተጨማሪ መረጃ እባክዎ alexandriava.gov/monkeypox ይጎብኙ።
First Name
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Last Name
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Date of Birth
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M-D-Y
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Street Address
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Suite, Apartment, Unit number
ZIP Code
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Email Address
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Phone Number
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Male Female Trans MTF Trans FTM Trans Unspecified Non-Binary Other Unknown Not Disclosed
Hispanic/Latino
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Yes
No
In the past 21 days, have you come in contact with anyone with suspected or confirmed monkeypox illness?
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Yes No
Selecting yes means you have been in contact with a person who has a positive MPV test result or is awaiting MPV test results when that person was having symptoms or not feeling well the last time you were with them.
If yes, provide the date of the last known exposure:
Today M-D-Y
What was the nature of your exposure?
Do you currently have any symptoms of monkeypox? Symptoms of monkeypox can include:Fever Headache Muscle aches and backache Swollen lymph nodes Chills Exhaustion A rash that 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.
Symptoms may include a single lesion or lesions on the genitals, anus and surrounding area, lesions in the mouth, and symptoms of proctitis (anal or rectal pain or bleeding) , especially if the individual has had a new sexual partner recently.
Yes
No
Not sure
Please describe your symptoms
Within the past 14 days, do any of the following statements apply to you?
I have had anonymous sexual contact or more than one partner I am a sex worker I am staff at an establishment where sexual activity occurs (e.g., bathhouses, sex clubs, swingers’ events) I have attended sex-on-premises venues (e.g. bathhouses, sex clubs, swingers’ events) I am living with HIV/AIDS I have been diagnosed with a sexually transmitted infection in the past three months * must provide value
Yes
No
In the past 14 days, do you identify as being in any of the following groups?
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Gay, bisexual, and other men who have sex with men and have had multiple (e.g. more than 1) or anonymous sexual partners
Transgender women and nonbinary persons assigned male at birth who have sex with men and have had multiple (e.g. more than 1) or anonymous sexual partners
Sex workers (of any sexual orientation or gender)
Staff (of any sexual orientation or gender) at establishments where sexual activity occurs (e.g., bathhouses, sex clubs)
Persons who attend sex-on-premises venues (e.g. bathhouses, sex clubs)
None of the Above
Do you have HIV, cancer, leukemia, other immune system problems, or are you on medications that significantly decrease your immune system?
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Yes
No