COVID-19 Vaccination Request Step 1 of 6 - Personal Information 16% Please do not submit duplicate registration requests as this may delay processing of your request. Personal InformationName* Legal First Name Legal Last Name Date of Birth Date Format: MM slash DD slash YYYY Date of Birth*SSNGender*-Select-MaleFemaleTransgender, male-to-femaleTransgender, female-to-maleNon-binary, male birthNon-binary, female birthPrefer Not to SpecifyWeightPlease enter a number from 1 to 999.Ethnicity*-Select-Hispanic or LatinoNot Hispanic or LatinoUnknownRace*-Select-Native American or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderOtherUnknown or Not ReportedWhite/CaucasianAre you a University of Kentucky HMO/PPO/EPO/RHP/SAVER member:*YesNo Contact InformationAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email If you do not have an email address please enter: firstname.lastname@example.org Occupation InformationAre you a University of Kentucky student or employee?*YesNoI am a...*UK HealthCare EmployeeUniversity of Kentucky EmployeeUniversity of Kentucky StudentUK ID*Are you a "First Responder" (e.g. law enforcement, firefighter, E.M.S., et cetera)?*If yes, be sure to bring your professional identification to your scheduled appointment.YesNoDo you work as school personnel for Kindergarten through 12th grade?*If yes, be sure to bring your professional identification to your scheduled appointment.YesNoDo you work directly in any of the following occupations/industries? Education outside of K-12 (Teachers, Support Staff, Daycare) Food & Agriculture Manufacturing U.S. Postal Service Public Transit Grocery or Deli Transportation and Logistics Food Service Shelter & Housing (Construction) Clergy Finance IT & Communication Energy Media Legal Public Safety (Engineers) Water & Wastewater Industry*YesNo Medical InformationWere you eligible for Phase1a COVID-19 vaccination (long-term care patient or healthcare worker)?*If you're unsure, please select "No". Individuals selecting 1a as a Health Care Worker must provide proof of employment (such as work ID) or licensure upon presenting for vaccinations.YesNoHave you received the first COVID-19 vaccine shot someplace other than UK HealthCare or Kroger Field Vaccination Center*YesNoYou must receive your booster vaccine shot from the same place that you received your first shot.Select one of the following:*-Select-This will be my first dose/shot of the vaccine.This will be my second (booster) for the vaccine.Which vaccine did you receive?*-Select-Pfizer-BioNTechModernaDate of first vaccine dose*During the past 90 days, have you received passive antibody therapy for COVID-19?*YesNoSpecifically, do you have any of the following health conditions: Cancer/Carcinoma Chronic Kidney Disease Chronic Obstructive Pulmonary Disease Down Syndrome Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies Immunocompromised state (weakened immune system) from solid organ transplant Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2) Severe Obesity (BMI ≥ 40 kg/m2) Pregnancy Sickle Cell Anemia Smoking Type 2 Diabetes Mellitus Additionally, do you have ANY of the following health conditions? Asthma (moderate-to-severe) Cerebrovascular disease (affects blood vessels and blood supply to the brain) Cystic fibrosis Hypertension or high blood pressure Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines Neurologic conditions, such as dementia Liver disease Overweight (BMI > 25 kg/m2, but < 30 kg/m2) Pulmonary fibrosis (having damaged or scarred lung tissues) Thalassemia (a type of blood disorder) Type 1 Diabetes Mellitus Additionally, do you have ANY of the following health conditions?*YesNo Vaccination Consent QuestionnaireAre you sick today, have a fever, a rash or Shingles?*YesNoPlease provide more details*Do you have allergies to ANY medication, food (e.g. eggs, nuts), latex or any vaccine component (e.g.neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin, baker’s yeast or yeast)?*YesNoPlease provide more details*Have you ever had a serious reaction after receiving a vaccination?*YesNoPlease provide more details*Have you had the vaccine(s) you are receiving today before?*YesNoPlease provide more details*Have you received any vaccinations or skin tests in the past 4 weeks?*YesNoPlease provide more details*Have you had seizures, Guillain-Barre Syndrome (GBS), or any neurological or brain disorder?*YesNoPlease provide more details*Are you pregnant, breastfeeding or do you plan on becoming pregnant in the next three months?*YesNoPlease provide more details*Are you a cigarette smoker or have diabetes, alcoholism or low immune system, cerebrospinal fluid leak, Cochlear implant, chronic heart, liver, or lung disease?*YesNoPlease provide more details*Do you have HIV/AIDS, organ transplant or bone marrow transplant, cancer, leukemia, lymphoma, multiple sclerosis, hematopoietic stem cell or any other immune system problem?*YesNoPlease provide more details* All the information provided is correct to the best of my knowledge. I authorize the following: the release of any medical or other information with respect to this vaccine to my healthcare providers, Medicare, Medicaid, or other third-party payer, as needed, as well as to the FDA. I acknowledge that my vaccination record may be shared with federal or state agencies for registry reporting; and that the provider or pharmacist recommends that I remain in the waiting area for 20 minutes after receiving the vaccine to be observed for a reaction. If I receive curbside vaccination, I understand it is still recommended to remain nearby for 20 minutes and to quickly notify the UKHealthCare staff of any reactions. I have had the opportunity to ask questions that were answered to my satisfaction and understand the benefits and risks of the vaccine(s). I give consent for the administration of the COVID-19 vaccine(s). I have read or have had read to me the Vaccination Information Sheet (VIS) regarding the vaccine(s), and I hereby acknowledge a scheduled receipt of the COVID-19 vaccine.Please enter your initials:*NameThis field is for validation purposes and should be left unchanged.