Covid Vaccine Question Title * 1. Please provide the following: Name * Address * Address 2 City/Town * Email Address Phone Number * Question Title * 2. Which Phase do you qualify for? 1A - healthcare worker and/or long-term care resident 1B tier 1 - Individuals 75 and older, Those at risk of exposure at work in the following sectors: education, childcare, emergency services, and food and agriculture 1B tier 2 - Individuals 65 -74 years of ageThose at risk of exposure at work in the following sectors: transportation and logistics; industrial, commercial, residential, and sheltering facilities and services; critical manufacturingCongregate settings with outbreak risk: incarcerated and homeless Don't know/Other (please specify) None of the above Question Title * 3. Employer/ Position Question Title * 4. Would you like to be contacted when you are eligible to be vaccinated? Yes No Question Title * 5. Are you an existing patient of Anderson Valley Health Center? Yes No Done
