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

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

Working …

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Required format:

Jefferson County Mpox Eligibility and Interest Form

Para ver este formulario en español, haga clic en el globo en la esquina superior derecha.

Recent cases of mpox have been identified in Colorado.

Some people who may have been recently exposed to mpox are recommended to receive the Jynneos vaccine. This vaccine has been fully approved by the FDA for the prevention of mpox in people aged 18 years and older. It currently has an Emergency Use Authorization to be used for people under the age of 18.

Getting vaccinated after a recent exposure lowers the chance of getting mpox. The sooner an exposed person gets the vaccine, the better. The vaccine can also reduce severity of symptoms if you do develop a mpox infection. Data shows that receiving the first dose of Jynneos vaccine offers early protection against mpox.

How to get vaccinated: If you think you may be eligible for the vaccine, complete the following form. Vaccine supply is currently extremely limited. Completing this interest form does not guarantee a vaccine appointment. If you qualify for a vaccine, you will receive an email with registration links to schedule your appointment, as vaccine supply allows.

If you are unsure if you should receive the Jynneos vaccine for monkeypox, you can find more information at the Jefferson County Public Health webpage: https://www.jeffco.us/4497/Monkeypox

NOTE: Jeffco residents who self-attest to being immunocompromised are still eligible to receive a second dose four weeks after their first to ensure they achieve maximum protection.

The following questions will determine if you are eligible for the mpox vaccine. If you are eligible, you will be able to register for a vaccine clinic, pending vaccine availability. You will receive an email with registration links to sign up for an appointment using PrepMod. You will not receive the vaccine without a scheduled appointment.

Mpox can spread through close physical contact like hugging, kissing, and oral and penetrative sex. Anyone who believes they have been in close contact with someone who has mpox in the last 14 days can also receive the vaccine. People can self-report if they are eligible for the vaccine, and do not need permission from a doctor.

Vaccination is free. You don't need health insurance or ID to get vaccinated.

You should especially consider getting vaccinated if

Your partner(s) are showing symptoms of monkeypox, such as a rash or sores that may begin on the genital area or the face, including in the mouth, and then spread to other parts of the body.
You recently met a partner whose sexual history/risk factors are unknown, such as:
- Through online platform such as Grindr, Tinder or Scruff.
- At a large gathering, such as a rave, club, sauna, sex party or other large gathering.

Note: People who currently have a fever, rash, or sores that may be due to mpox cannot get vaccinated. Instead, they should separate from others and contact a health care provider to get tested. Treatment may be an option. More information about isolation can be found in the JCPH Mpox FAQ: https://www.jeffco.us/4497/Monkeypox

First Name:

Last Name:

Phone Number

* must provide value

Are you experiencing any of the following symptoms?

Rash (rash can look like pimples or blisters that appears on the face, inside the mouth, and on other parts of the body, like the hands, feet, chest, genitals, or anus)

AND

Flu-like symptoms (such as, fever, chills, swollen lymph nodes, exhaustion, muscle aches and backaches, headache, respiratory symptoms (e.g., sore throat, nasal congestion, or cough))

* must provide value

Yes

Jefferson County Mpox Eligibility and Interest Form

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