Mpox Vaccine Assessment

Chester County Health Department

The Chester County Health Department is providing vaccinations to protect against mpox to individuals at high risk of exposure or serious illness.

Vaccination supply is currently limited and therefore require you to respond to assessment questions to determine your eligibility. The assessment includes demographic, medical history, and sexual activity related questions. All your responses are confidential and safely secured. The information you provide is used by Health Department staff to determine your eligibility.

You are not guaranteed a vaccine by completing this assessment.

Individuals will be contacted to schedule an appointment by the Health Department if you meet the eligibility criteria.

This form is HIPAA compliant, meaning your health information will be protected. Your personal information will be used to connect you to mpox vaccine.

Thank you for trusting us with your care.

If you have any questions about Mpox or vaccines/treatments, please call the Health Department at 610-344-6225 or go to the CDC mpox information page.

Have you had a known or suspected exposure to someone with mpox?

YesNo

Have you had a sex partner in the past 2 weeks who was diagnosed with mpox?

YesNo

Are you a gay, bisexual, or other man who has sex with men, or a transgender, nonbinary, or gender-diverse person AND have you received a new diagnosis of one or more sexually transmitted diseases in the last 6 months? (e.g., chlamydia, gonorrhea, or syphilis)

YesNo

Are you a gay, bisexual, or other man who has sex with men, or a transgender, nonbinary, or gender-diverse person AND have you had sex with more than one sex partner in the last 6 months?

YesNo

In the last 6 months, have you had sex at a commercial sex venue (e.g., sex club or bathhouse)?

YesNo

In the last 6 months, have you had sex related to a large commercial event or in a geographic area where mpox virus transmission is occurring?

YesNo

Do you have a sex partner with any of the risks listed above?

YesNo

Do you anticipate attending or experiencing any of the above scenarios in the future?

YesNo

Are you at risk for occupational exposure to orthopoxviruses (e.g., certain individuals who work in a laboratory or healthcare facility)?

YesNo

Thank you for completing the mpox vaccination survey.

Please provide your name, phone number, and email address. A Chester County Health Department staff member will reach out to you directly.

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Thank you for completing the mpox vaccination survey.

Do you have any additional questions you would like to discuss with someone?

If yes, please provide your name, phone number, and email address. A Chester County Health Department staff member will reach out to you directly.

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email Address

example@example.com

Please answer the following questions: