DSAMN Vaccine Interest Form

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In yesterday's press conference, Governor Walz said we have moved to Phase 1B, Priority 2 group as of 3/10/2021. That is the group that individuals with Down syndrome and other rare conditions or disabilities that put them at high risk are in. We are already seeing some opportunities for adults with Down syndrome/high-risk conditions to get a vaccination. We will do our very best to help everyone get vaccinated.

IMPORTANT REMINDER: This is for individuals with Down syndrome and other rare conditions or high-risk disabilities ages 16 and older. There are no vaccines yet available for people under 16. There is only one vaccine approved for 16 and 17 year olds (Pfizer), so we have to take special care with that population to make sure we can find the Pfizer vaccine. This list will help us get ahead of it.

PLEASE SHARE THIS WITH OTHER FAMILIES.

Email *

Name of Household Member with Down syndrome or other rare condition or disability *

Birthdate of Household Member with Down syndrome or other rare condition or disability *

YYYY

Vaccine Interest

Yes, my loved one with Down syndrome (or rare condition or disability eligible under 1a, priority 2) would like the vaccine when available

No, my loved one was already vaccinated

Unsure, or I have some questions - please call or email me

Clear selection

Have you filled out the Vaccine Connector for your loved one with Down syndrome

Yes

I need help with that, please have someone contact me.

Clear selection

Comfortableness with healthcare professionals/settings (check any/all that apply)

My loved one is only comfortable with healthcare professionals he/she knows

My loved one would be comfortable in a pharmacy setting

My loved one would be comfortable in a clinic setting that is unfamiliar to them

My loved one would be comfortable at a large scale event (might be louder/more people)

I am unsure, I think they'd be comfortable with unfamiliar healthcare professionals, but I would really prefer it be someone we know is good with adults with Down syndrome

I am comfortable navigating and parking Downtown/in a ramp

I would prefer surface parking

We need easy/accessible parking due to mobility issues

Other:

How far can you/your loved one travel for an appointment

Up to 10 miles

Up to 25 miles

Up to 50 miles

Up to 100 miles

I would travel more than 100 miles

Clear selection

How much time do you need to prepare your loved one to receive the vaccine

I would need 3 or more days notice to arrange transportation, switch schedules, and/or make my loved one comfortable

I would be fine with 1 to 2 days notice

I would be able to figure it out with 12-24 hours notice

I could get somewhere immediately

Clear selection

Vaccine Manufacturer/Allergies/Anxiety

My loved one has some anxiety, 1 shot would be better, but we are open to both

My loved one is 16 or 17, has to take Pfizer

Other:

Clear selection

Do you need help scheduling your own shot as a caregiver

Yes

Clear selection

Your First Name *

Your Last Name *

Your Phone Number *

Street Address *

City *

State *

Zip *

Send me a copy of my responses.

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