Please complete this survey if interested in receiving a COVID-19 vaccination from BBPH.

This is not registration for an appointment to receive COVID-19 vaccine.

Completing this survey identifies what priority group you qualify for and puts your name on a list for public health staff to contact you once your priority group is eligible to be vaccinated.

Staff will email you with COVID-19 vaccination appointment information once vaccine is available for your priority group.

If you do not have an email address, please note that in the comments section and we will call you.

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* 1. Contact information for individual requesting vaccine. (If you reside outside of Burleigh County, please contact your local public health department for COVID-19 vaccine information)

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* 2. Date of Birth:

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* 3. Age:

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* 4. What priority group do you fit into?  

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* 5. Please list any comments or questions if you have them.

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