If you meet Phase1B criteria as an individual over the age of 75 years old and live in the Roanoke City and Alleghany Health District, please complete this survey. 

Roanoke City & Alleghany Health District (RCAHD) includes: Alleghany County, Botetourt County, Craig County, City of Covington, City of Roanoke, Roanoke County, and the City of Salem.

Once this survey is submitted, a member of the Roanoke City and Alleghany Health District will follow up to discuss vaccine opportunities once vaccine supply becomes available. 

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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth (mm/dd/yyyy)

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* 4. City/County of Residence

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* 5. Phone Number (10-digit number to include area code)

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* 6. Email Address

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