PLEASE NOTE: Vaccination of PHASE 1B populations has NOT started yet. By completing this survey, you will be placed on an information distribution list tailored to your eligibility group. Not all eligibility groups are defined by the state at this time. As soon as we can anticipate when your eligibility group may receive vaccine, we will contact you to schedule your vaccination. Please be sure to double check your email address and phone number so we have the correct contact information. This is for those people who are not being vaccinated through some other channel.

This survey will not guarantee you a place in line but it will be used by us to reach out to you when your group is eligible for a COVID-19 vaccine. If you are responsible for someone else's care (legal guardian, etc.), you may complete this on their behalf but please be sure they are able to receive the vaccine and to provide contact information that will allow us to reach out as appropriate.

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* 1. Last Name

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* 2. First Name

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* 3. Email address

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* 4. Preferred Contact Phone Number

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* 5. Home Address

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* 6. If any one or more of the following eligibility circumstances apply to you (or the person you represent), please answer "yes". If not, answer "No". We are asking to determine which group you are in with the state's distribution prioritization plan.
- Aged 65 or older
- An adult (18+) living with a severe congenital, developmental, or early-onset medical disorder that makes them particularly vulnerable. This includes cerebral palsy; spina bifida; congenital heart disease; type 1 diabetes; inherited metabolic disorders; severe neurological disorders including epilepsy; severe genetic disorders including Down Syndrome, Fragile X, Prader Willi Syndrome, and Turner Syndrome; severe lung disease including cystic fibrosis and severe asthma; sickle cell anemia; and alpha and beta thalassemia.
- An adult (18+) who works in a school (teacher, staff, administration, transportation, dietary, environmental, etc).

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* 7. To which of the following eligible groups do you (or the person you represent) belong?

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* 8. If offered and eligible, will you take the vaccine? (You may change your mind but we want to get a head count for planning purposes.)

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