COVID-19 Vaccine Screening Questionnaire

You must complete the questionnaire below to verify you are eligible for vaccination at this time. These POD’s are operated by the respective provider, questions regarding appointments can be directed to the provider.

Note: Enrolling in multiple appointments at multiple sites will void your appointments. Please enroll in only 1 appointment.

I attest that I am at least 16 years of age and either live or work in the state of Illinois. (Note: Only Pfizer vaccine has been approved for individuals 16 years of age and older.)

I attest that the information I provide is voluntary and the above answers are truthful and accurate. I understand that providing inaccurate answers may result in my appointment being voided. I give my consent for Illinois Department of Public Health (IDPH) to use my personal health information to administer the COVID-19 vaccine(s), help prevent and control the spread of COVID-19, and for other purposes as stated in IDPH's privacy practices. I accept the Privacy Policy and Terms of Service for this service.

I authorize IDPH to send me appointment reminders and notify me of my COVID-19 vaccine appointments at the provided email address and phone number. Message and data rates may apply.