Week 7 Lab

COVID-19 Screening Questionnaire

Please fill-out your contact information:

First Name

Last Name

Email address

Address

City

Zip

Telephone number

Gender

How Your Information will be used

The information that you provide to Hilo Vacinnation Associataion (HVA) will only be used for the purpose of determining if you are eligible for the COVID-19 vaccination shot. All information provided is strictly confidential and will not be shared to any third-party entity. We stictly follow the Health Insurance Portability and Accounting Act (HIPAA) reqiuremens and guidelines.