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COVID-19 Vaccine Appointment Form

Medical practices use this form to schedule COVID-19 vaccine appointments and collect relevant demographic and workplace information from the patient.

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Appointment

Date

Time

Name

Nombre

Apellido

Phone Number

Zip Code

Date of Birth

What is your gender assigned to birth?

What is your current gender?

What is your ethnicity?

Height (ft)

Weight (lb)

Are you currently employed?

Yes No

Do you work from home?

Yes No

What is the possible nearest date for you to work from main office?

Zip code for your main office

How often do you go in person to your main workplace currently?

Daily Weekly Monthly Never

Does your main workplace have social distancing measures in place?

Yes No

Do you and other people in your main workplace use personal protection equipment such as masks?

Yes No

How do you get to work? (select all that apply)

Private car Public transport Carpool Walking or biking

In general, how many people do you physically interact with in your main workplace?

1 to 5 6 to 10 11 to 20 More than 20

How many people live in your household? (including you)

1 2 to 3 4 to 5 6 or more

Is there anyone in your household who is older than 64?

Yes No

Is there anyone in your household who attends school or child care?

Yes No

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