Waiting List For Receiving First Dose of COVID Vaccine at CCACC 第一針新冠疫苗注射意願調查表
CCACC is working with Montgomery County to help with COVID vaccination efforts. If you would like to receive updated further information about this event, please leave your contact information here.

CCACC 正與蒙郡合作提供新冠疫苗注射事宜。你如果想得到這方面的最新消息，請你留下通訊信息。

You can subscribe our e-newsletter here 你也可以訂閱我們的電子通訊：

English: https://mailchi.mp/0e9343ca9618/zi6egldrn3 ; 中文: https://mailchi.mp/4ea2b70c78f8/iqwbp9q1eg

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Official Last Name 姓： *
Official First Name 名： *
Middle Initial: 中間名
Date of Birth 生日： *
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Email Address 電郵地址： *
Phone Number 電話號碼: *
Are you a Montgomery County Resident? 您是否為蒙郡居民? *
Do you have transportation? 您是否有交通工具? *
Do you have any health insurance? 請問您有無任何醫療保險? *
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Mother's Maiden Name  媽媽的姓氏 : *
Race 種族 *
Ethnicity 族裔 *
Gender 性別 *
Address 住址 *
City 城市 *
Zip code 郵遞區號 *
County 郡 *
Is this your first, second, or third COVID-19 vaccination? 請問這是您的第一針,第二針,或第三針新冠疫苗? *
Do you have any of the following chronic health conditions? 請問您是否有以下慢性疾病? *
Required
Have you previously received a COVID-19 vaccine? 請問您之前接種過新冠疫苗嗎? *
Do you have a history of anaphylaxis or anaphylactic reaction after vaccination or other injectable medications; to food (e.g., nuts/tree nuts, shellfish, eggs); insect bites (e.g. bee stings); venom; latex; or any other item not listed? 您之前對於其他疫苗或注射藥品有無嚴重過敏反應；有無食物過敏，如:堅果，海鮮或蛋；蚊蟲叮咬，如:蜂螫；乳膠或其他物質過敏? *
Do you have a bleeding disorder or are you taking a blood thinner? 請問您有無凝血疾病，或有無在使用抗凝血劑? *
Are you immunocompromised (have a weakened immune system such as cancer, leukemia, HIV/AIDS, or any other immune system problem) or are you taking medication that affects your immune system? 請問您有無免疫力低下的疾病(如:癌症，白血病，愛滋，或其他免疫系統相關問題)或您有無在吃會影響您免疫系統的藥物? *
Do you have a fever? 請問您有無發燒? *
Are you feeling sick? 現在有無覺得不舒服? *
Are you pregnant? 有無懷孕 *
Could you become pregnant in the next several weeks? 您在未來幾周有可能會懷孕嗎? *
Are you breastfeeding (nursing)? 您目前有在哺乳嗎? *
Have you received any other vaccinations in the last 14 days? 請問你在14天內有無接種過其他任何疫苗? *
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? 請問您之前有無因為要治療新冠而接受過單株抗體或抗血清治療? *
Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? 您是否曾有新冠檢測結果呈陽性,或曾有醫生告知您,您感染了新冠? *
If eligible, our staff will call you back to complete the registration process. Thank you for completing our survey! 如果您符合資格,我們將以電話聯繫您,完成註冊的程序。謝謝您完成我們的問卷!
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