Antibody pre-registration
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First Name:
Nombre:
Middle Initial:
Inicial del segundo nombre:
Last Name:
Apellido:
Maternal Last Name:
Apellido maternal
Date of Birth:
Fecha de nacimiento:
Gender:
Sexo:
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Male
Female
Ethnicity:
Etnicidad:
Hispanic, Latino, or Spanish origin
Not Hispanic, Latino, or Spanish origin
Race:
Raza:
White
Black or African American
American Indian or Alaskan Native
Asian (Chinese, Vietnamese, Filipino, Korean, Asian Indian, Japanese, other)
Pacific Islander (Native Hawaiian, Samoan, Chamorro, other)
Other Race
Hispanic, Latino, or Spanish origin
Phone Number:
Número de telefono:
Email:
Correo electrónico:
Home Address:
Dirección de casa:
Home City:
Ciudad:
Home State:
Estado:
Home Zip Code:
Código postal:
Are you part of any of the following special interest categories?:
¿Eres parte de alguna de las siguientes categorías de intereses especiales?:
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Grocery store employee
Healthcare worker
First responder (not identified in previous question)
Long term care facility - staff
Long term care facility - resident
Agricultural farm labor
Agricultural food processing
Homeless
Have you ever tested positive for COVID-19?
¿Alguna vez ha dado positivo por COVID-19?
Yes
No
Do you work for a first responder agency or the City of Oxnard as non-public safety?
¿Trabaja para alguna agencia de primeros auxilios o para la ciudad de Oxnard, pero no como parte de la seguridad pública?
Yes
No
Agency
Agencia
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Oxnard Fire Department
Oxnard Police Department
Ventura City - Fire Department
City of Oxnard Non-Public Safety
Ventura City - Police
Ventura City - Harbor District
AMR/GCA
Port Hueneme - Police
Simi Valley - Police
Federal Fire Department
CA State Parks
Santa Paula - Police
Ventura College - Paramedic Program
CSUCI - Police
NBVC - Police
Fillmore - Fire Department
CA Fish & Game
Ventura County - Fire Department
Ventura County Sheriff's Office
Ventura County District Attorney
Ventura County Community College District
Ventura County Medical Examiner
Ventura County - Public Health
Los Padres National Forest
CAL FIRE
Santa Monica - Fire Department
Santa Monica - Police Department
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