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Monkeypox Vaccination Eligibility Questionnaire (9/19/2022)
Name (First name, middle initial, and last name)*
Student ID Number*
Phone Number*
Today's Date*
Date of Birth*
1. Have you traveled to a country where Monkeypox is an endemic disease? (i.e. Central and West Africa)
YES
NO
2. In the past 14 days have you had close or intimate contact with someone with a similar rash or confirmed case of Monkeypox?
YES
NO
MAYBE
3. Do you have multiple sex partners?
YES
NO
4. Do you have intimate or sexual contact with a person/people you did not previously know? (i.e. dating apps, commercial sex venues, or other methods of anonymous sex)
YES
NO
5. Do you attend venues where you have close physical contact with other people and anonymous or group sex may occur? (i.e. raves, clubs, parties, bars and other crowded places)
YES
NO
6. Are you employed in a laboratory that handles cultures of orthopox virus?
YES
NO
7. Are you employed in a laboratory that performs testing for orthopoxviruses?
YES
NO
8. Are you a healthcare worker who performs orthopoxvirus generic testing to diagnose orthopox viruses?
YES
NO
9. Have you been diagnosed with gonorrhea or syphilis in the past 6 months?
YES
NO
10. Are you an individual living with HIV?”
YES
NO
11. Do you use, or are you eligible to use, HIV PrEP (medication to prevent HIV infection, i.e. Truvada, Descovy, or Apretude)?
YES
NO
12. Do you engage in commercial and/or transactional sex? (i.e. sex in exchange for money, shelter, food, and other goods/needs).
YES
NO