1. Are you moderately or severely ill today? Mild illness or taking antibiotics are not reasonable reasons for withholding a vaccination.

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2. Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or Epi Pen or for which you had to go to the hospital?

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3. Have you ever had a serious reaction after any vaccination or injectable medication including a previous dose of the COVID-19 vaccine?

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4. In the past 14 days have you tested positive for COVID-19 or had contact with a lab confirmed COVID-19 patient?

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5. Are you breastfeeding or pregnant?

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6. Have you received passive antibody therapy as treatment for COVID-19?

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7. Are you immunocompromised? (taking medication or being treated for cancer, leukemia, HIV/AIDS or other immune system problems or taking medication that affects your immune system).

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8. Do you currently have or have had a history of neurological condition, seizures, or have ever had Guillain Barre’ Syndrome?

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9. Have you ever received a dose of COVID-19 vaccine?

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