Are you interested in receiving the COVID-19 Vaccine?

Based on availability, and guidance from the Missouri Department of Health and Senior Services (MO DHSS) and the Center for Disease Control (CDC), the Moniteau County Health Center will be providing the COVID-19 vaccine based on a pre-determined phase system. Individuals will be identified to receive the vaccine based on risk status and occupation. 

Once the vaccine is made available for your phase, the Moniteau County Health Center will use your information from the survey below to contact you with further instructions on how to schedule an appointment to receive your vaccination. 

COVID-19 vaccinations will not be provided to those under the age 18.

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* 1. What is your name?
You must provide your name if you would like to be alerted of vaccine availability.

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* 2. What is your current age?

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* 3. How would you describe your race?

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* 4. What is your zip code?

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* 5. What is your phone number? This will be used to alert you when the vaccine is available to your assigned phase.

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* 6. What is your email address? This will be used to alert you when the vaccine is available to your assigned phase.

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* 7. What is your work status?

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* 8. Are you employed by any of the following types of patient-facing organizations: hospital, physician's office, behavioral health, dialysis center, outpatient healthcare, dental office, other healthcare, school district-nurse, or EMS?

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* 9. Please provide the name of your employer.
This helps determine what phase you will qualify for the vaccine.

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* 10. What is your job title and/or role at your organization?

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* 11. Do you have any pre-existing medical conditions? Please select all that apply.

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* 12. I consent to receive email notifications regarding COVID-19 vaccination availability and clinic opportunities based on my assigned phase?

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* 13. I consent to receive text message notifications or phone calls regarding COVID-19 vaccination availability and clinic opportunities based on my assigned phase? Message and data rates may apply.

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