The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

r6uIJiuIxtXXaHwwdnCTMv6bRjwHbTAfXczfRRw648Nr8JTUbL3rdcfMoLIVcvE4Gkd2o75HTR9bwIa4ZLoJFD

Mpox Vaccine Request/Screening Form

If you believe you may be at risk of having an exposure to mpox (or monkeypox) in the last 14 days and are interested in the mpox post-exposure vaccine, please complete the screening form below. Please provide complete information. Once your information has been reviewed and triaged by a public health nurse, we will contact you. Please submit one survey per person.

Your information and survey response will only be reviewed by the authorized individuals at the Loudoun County Health Department.

The Health Department has received a small amount of vaccine from VDH. Further updates will be provided as additional vaccine supplies become available. For additional information regarding prevention and lowering your risk, please see Social Gatherings, Safer Sex, and Mpox | Mpox | Poxvirus | CDC.

Date of Submission:

M-D-Y

First Name:

Last Name:

Date of Birth:

Age:

View equation

Street:

City:

State:

Zip Code:

Primary Phone Number:

Have you previously received a smallpox vaccine or a dose of the monkeypox vaccine (JYNNEOS or ACAM2000)?

Yes

reset

If yes, provide date of last vaccination:

M-D-Y

Years since last smallpox vaccine

View equation

Have you previously been diagnosed with monkeypox infection?

Yes

reset

If yes, provide date of your most recent positive monkeypox test:

M-D-Y

Have you come in contact with anyone with suspected or confirmed mpox illness?

Selecting Yes means you have been in contact with a person who has a positive mpox test result or is awaiting mpox test results when that person was having symptoms or not feeling well the last time you were with them.

Yes

reset

If yes, provide date of last known exposure:

M-D-Y

Do you identify with any of the following groups: Gay, bisexual, transgender women, or nonbinary persons assigned male at birth who have sex with men?

Yes

reset

Have you had multiple (e.g. more than 1) or anonymous sexual partners in the last 14 days, regardless of sexual orientation or gender?

Yes

reset

If yes, provide the date(s):

Are you a sex worker (of any sexual orientation or gender)?

Yes

reset

Are you a staff member at an establishment where sexual activity occurs?

Yes

reset

Are you a sex worker or a staff member at an establishment where sexual activity occurs?

Yes

reset

If yes, what are the estimated date(s)?

If yes, in what town or city?

Do you have HIV, or have you been diagnosed with any sexually transmitted infection in the past 3 months?

Yes

reset

Do any of the following statements apply to you?

I have had anonymous sexual contact or more than one sexual partner in the last two weeks
I am a sex worker
I am a staff member at an establishment where sexual activity occurs
I am living with HIV/AIDS
I have been diagnosed with a sexually transmitted infection in the past three months

Yes

reset

Do any of the following statements apply to you?

I have had a sex partner in the past 2 weeks who was diagnosed with mpox
I am a gay, bisexual, or other man who has sex with men or a transgender, nonbinary, or gender-diverse person who in the past 6 months has had any of the following:
- A new diagnosis of one or more sexually transmitted diseases (e.g. chlamydia, gonorrhea, or syphilis)
- More than one sex partner
You have had any of the following in the past 6 months:
- Sex at a commercial sex venue (like a sex club or bathhouse)
- Sex related to a large commercial event or in a geographic area (city or county for example) where mpox virus transmission is occurring
You have had a sex partner with any of the above risks
You anticipate experiencing any of the above scenarios
You have HIV or other causes of immune suppression and have had recent or anticipate future risk of mpox exposure from any of the above scenarios
You work in settings where you may be exposed to mpox:
- You work with orthopoxviruses in a laboratory
- You are part of an orthopoxvirus and health care worker response team

Yes

reset

Comments:

Expand

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Mpox Vaccine Request/Screening Form

Vaccine Recipient Information

Screening & Risk Assessment Questions

You have selected an option that triggers this survey to end right now.