Montgomery County Tier 1a Vaccine Pre-Registration for Health Care Staff

The Montgomery County Department of Health and Human Services is currently working through the remaining members of vaccine Priority 1a. We currently are administering Moderna vaccine in a two-dose series, 28 days apart.

Priority 1a includes the following groups:

EMS
COVID testing and vaccination staff
Public Health – COVID response
Urgent Care
Primary Care
Surgical Centers
Other health care professionals (e.g., outpatient specialties, allied health, optometrists, physical therapists, podiatrists, community health workers, in-home nursing staff)
Pharmacists
Dental practices
Patient-facing, licensed social workers
Detention Center staff
Homeless shelter staff
First Responders (Law enforcement (patrol/public-facing); Fire rescue; 9-1-1 dispatchers)
Behavioral health (non-telehealth) – e.g., residential/recovery
School nurses
Medical Lab workers
Morticians/funeral home staff
Other providers licensed by Maryland Department of Health

Each unvaccinated member of Tier 1a who reside or work for a 1a practice in Montgomery County should complete the following form.

After vetting the information provided and once we have an available supply of vaccine, we will contact individuals who have registered with information on how to set up an vaccination appointment. Please note that we are receiving a very high number of requests and have a very limited supply of vaccine each week. We will continue working through the list until all health care providers are vaccinated.

For questions or the latest information on the status of vaccination operations, please check our website: https://www.montgomerycountymd.gov/covid19/vaccine/

Thank you!

Question Title

* 1. Please select the type of practice that best describes your Tier 1a organization.

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* 2. Tier 1a Organization Contact Information:

Organization Name: *

Organization Address *

(Suite/Apt/etc)

Organization City/Town *

Organization State *

Organization ZIP/Postal Code *

Organization Phone Number *

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* 3. Tier 1a Employee Contact Information:

Employee Name *

Employee Position in Organization: *

Employee Address *

(Suite/Apt/etc)

Employee City/Town *

Employee State *

Employee ZIP Code *

Employee Email Address *

Employee Phone Number *

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* 4. Do you hold a current State of Maryland occupational license?

Yes (please specify)

Montgomery County Tier 1a Vaccine Pre-Registration for Health Care Staff

Question Title

* 1. Please select the type of practice that best describes your Tier 1a organization.

Question Title

* 2. Tier 1a Organization Contact Information:

Question Title

* 3. Tier 1a Employee Contact Information:

Question Title

* 4. Do you hold a current State of Maryland occupational license?

Question Title

* 5. Comments