Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Monkeypox Vaccination Questionnaire

  1. Please answer the following questions to determine if you are eligible to receive vaccination against monkeypox virus (MPV). Please note that vaccination is NOT recommended for the general public at this time, but rather for close contacts of cases or those at higher risk of exposure.

    A * and/or red shaded field indicates the response is required.

  2. Are you 18 years of age or older?
  3. Are any of the following statements true for you? You do not need to specify which statement applies.*
    • I have had prolonged skin-to-skin contact with someone who was exposed to monkeypox (MPV)
    • I am a gay or bisexual man or transgender person who has sex with men, and I have had multiple or anonymous sex partners in the last 6 months
    • I have used methamphetamine in the last 6 months
    • I have exchanged sex for money, drugs, or other purposes in the last 6 months
    • I have been sexually assaulted (regardless of gender or sexual orientation)  
    • I have been diagnosed in the last 12 months with one or more nationally reportable sexually transmitted diseases (such as acute HIV, chancroid, chlamydia, gonorrhea, or syphilis)
    • I have attended a bathhouse, public sex venue, or had group sex (at least 3 people at the same time) in the last 6 months
    • I have been incarcerated in the last 6 months
    • I am currently taking PrEP to prevent HIV infection
    • I am currently experiencing or have experienced homelessness/unstable housing in the last 6 months (could include living in a shelter, car, or congregate setting; “couch surfing”; staying with friends or relatives; migratory work in agriculture or seafood industries) AND meet at least one of the other criteria listed here.
    • I am Black, Hispanic/Latinx, Native Hawaiian, Pacific Islander, Asian, Indigenous, or American Indian/Alaska Native, AND I meet at least one of the other criteria listed here.
  4. Which of the following locations would you prefer for a vaccination appointment?*

    You may select more than one location

  5. Would this be your first or second dose of the MPV vaccine?
  6. Leave This Blank:

  7. This field is not part of the form submission.