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...

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

JYNNEOS Vaccine Assessment

Please complete the questions below to schedule an mpox vaccination appointment.

Two doses of JYNNEOS should be received, with at least 4 weeks separation between doses.

If it has been more than 4 weeks since the first dose, the second dose can be administered as soon as possible, and the series does not need to be restarted.

If you have already received two doses, there is not a need for a third dose at this time.

All information is confidential, and your personal information will not be shared.

County

* must provide value

Date of Survey:

* must provide value

M-D-Y H:M:S

First Name

* must provide value

Last Name

* must provide value

Street Address

Dirección de Hogar

* must provide value

City

Ciudad

* must provide value

State

Estado

* must provide value

Zip Code

Código Postal

* must provide value

Please specify other county:

Date of birth

* must provide value

M-D-Y

Phone number

* must provide value

E-mail

* must provide value

Age (years)

Edad (Anos)

View equation

Do any of the following apply to you?

You had known or suspected exposure to someone with mpox
You had a sex partner in the past 2 weeks who was diagnosed with mpox
You are a gay, bisexual, or other man who has sex with men or a transgender, nonbinary, or gender-diverse person who in the past 6 months has had any of the following:
- A new diagnosis of one or more sexually transmitted diseases (e.g., chlamydia, gonorrhea, or syphilis)
- More than one sex partner
You have had any of the following in the past 6 months:
- Sex at a commercial sex venue (like a sex club or bathhouse)
- Sex related to a large commercial event or in a geographic area (city or county for example) where mpox virus transmission is occurring
- Sex in exchange for money or other items
You have a sex partner with any of the above risks
You anticipate experiencing any of the above scenarios
You have HIV or other causes of immune suppression and have had recent or anticipate future risk of mpox exposure from any of the above scenarios
You work in settings where you may be exposed to mpox:
- You work with orthopoxviruses in a laboratory
- You are part of an orthopoxvirus and health care worker response team

* must provide value

Yes

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It is not recommended for you to receive a JYNNEOS Mpox vaccination at this time. Please call the clinic at 402-444-7112 with any further questions or to schedule other sexual health visits.

It is not recommended for you to receive a JYNNEOS Mpox vaccination at this time. Please call the clinic at (402) 441-8065 with any further questions or to schedule other sexual health visits.

It is not recommended for you to receive a JYNNEOS Mpox vaccination at this time. Please call the clinic at 402-727-5396 with any further questions or to schedule other sexual health visits.

It is not recommended for you to receive a JYNNEOS Mpox vaccination at this time. Please call the clinic at (712)-242-1155 with any further questions or to schedule other sexual health visits.

Below is the current clinic schedule. Please select a date and time for your appointment during open hours. If these dates and times do not work, please call the Douglas County clinic at 402-444-7112 to check other availability.

Below is the current clinic schedule. Please select a date and time for your appointment during open hours. If these dates and times do not work, please call the clinic at (402) 441-8065 to check other availability.

Below is the current clinic schedule. Please select a date and time for your appointment during open hours. If these dates and times do not work, please call the clinic at 402-727-5396 to check other availability.

Please call the Pottawattamie Clinic at (712)-242-1155 to schedule an mpox vaccination appointment

Choose appointment date and time based on schedule listed above

* must provide value

M-D-Y H:M

Scheduled Appointment Date

* must provide value

Scheduled Appointment Time

* must provide value

What is your preferred language?

¿Cuál es su idioma preferido?

English / Inglés

Spanish / Español

Other / Otros

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Ethnicity

Etnicidad

Hispanic or Latino / Hispano o Latino

NOT Hispanic or Latino / No Hispano o Latino

Unknown/Prefer not to say / Desconocido/Prefiero no decirlo

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Race

Raza

Do you identify as:

¿Se Identificas Como:

* must provide value

Female / Mujer

Male / Hombre

Transgender / Transgénero

Non-binary/Gender fluid / No Binario/Fluido de Genero

Other / Orto

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Specify Other:

Especifique Orto:

Name of healthcare provider who referred you to this survey:
If no referral, please enter 'self'

Nombre del médico que le ha remitió a esta encuesta:
Si no hay remisión, escriba "yo mismo."

Name and location of your healthcare provider's clinic:
If no referral, please enter 'self'

Nombre y ubicación de la clínica de su proveedor de servicios médicos
Si no ha sido remitido, introduzca "yo mismo"

Please click 'Submit' to proceed to the next section.
Haga clic en "Submit" para pasar a la siguiente sección.

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

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.