If you are a health care worker, first responder, USPS worker, critical utility worker, education or childcare worker, public transit employee, airline employee, food production worker (e.g. farmer, rancher NOT food service), grocery store employee, or manufacturing worker and have not been registered to receive vaccine through your employer, please complete the survey below. Please make sure all information is entered correctly as this is what will be used to register you in the federal system. We will evaluate and process your request as quickly as we can. We greatly appreciate your patience. If you don't hear back from us within a week, you do not meet the current allocation criteria. We will hold onto your information until you qualify. Note: If you are 75 and older, please apply through the links on kauai.gov to receive your vaccine through one of the hospitals (KVMH, Wilcox, Mahelona). Individuals who work in the following fields do not qualify until phase 1c: food service (e.g. restaurant employees), hotel employees, car rental employees, construction, engineering, hardware stores, transportation/logistics, lawyers, financial sector employees, etc.) Please refer to the state's plan at https://hawaiicovid19.com/ for further information.

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* 1. Applicant's first name

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* 2. Applicant's last name

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* 3. Applicant's Email Address (please make sure this is entered correctly as it will be used to register you)

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* 4. Agency/Facility where applicant works in one of the qualified fields listed above

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* 5. Agency/Facility's Physical Street Address

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* 6. Agency/Facility's Contact Number

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* 7. Are there other employees at your facility who have not been offered the vaccine but qualify for coverage? If yes and if there are fewer than 10, please direct them to complete this survey using their own unique email address since the system can only register one person per email. If you have more than 10 people who qualify for vaccine coverage during phase 1b, please call us at 808-241-3495 so we can coordinate the necessary information for your entire facility.

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