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

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Mpox (Monkeypox) Vaccine Interest Form

Chickahominy Health District is offering vaccinations to protect against monkeypox to some individuals who live, work, or spend time in Charles City, Goochland, Hanover, and New Kent counties and are at higher risk of exposure or serious illness.

Vaccination supply is currently limited. You are not guaranteed a vaccine by filling out this form. However, you will be added to a list to potentially receive a vaccine in the future depending on your risk factors and the available supply. This survey is HIPAA compliant, meaning your health information will be protected and information from this survey is only reviewed by two health department staff who are scheduling appointments. It is not shared with anyone outside the health department. If you prefer to remain anonymous, you can put a nickname or preferred name in place of your given name.

For more information on mpox, visit vdh.virginia.gov/surveillance-and-investigation/mpox/

The Virginia Department of Health is updating webpages with the term "mpox" in place of "monkeypox" to reduce stigma and other issues associated with prior terminology. This change is aligned with the recent World Health Organization decision. Both names may be used simultaneously while “monkeypox” is phased out.

What should we call you?

Are you at least 18 years of age?

* must provide value

Yes

Mpox (Monkeypox) Vaccine Interest Form

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