PHASE 1A/1B COVID-19 VACCINATION INTEREST SURVEY

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.

Question Title

* 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)

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2. Date of Birth:

Question Title

* 3. Age:

Question Title

* 4. What priority group do you fit into?

Phase 1A - Healthcare workers/Long-term Care/First Responders

Phase 1B - Persons age 75 and older

Phase 1B - Persons age 65-74 with two or more *high-risk medical conditions. (*Cancer, chronic kidney disease, COPD, Down Syndrome, heart conditions, organ transplant, obesity/severe obesity, pregnancy, sickle cell disease, smoker, diabetes, asthma, cerebrovascular disease, cystic fibrosis, hypertension/high blood pressure, immunocompromised state, neurologic conditions, liver disease, pulmonary fibrosis, blood disorder).

Phase 1B - Staff and persons living in other congregate settings (i.e., corrections, group homes, treatment centers, homeless shelters, etc.)

Phase 1B - Persons age 65 and older with one or more *high-risk medical conditions. (*Cancer, chronic kidney disease, COPD, Down Syndrome, heart conditions, organ transplant, obesity/severe obesity, pregnancy, sickle cell disease, smoker, diabetes, asthma, cerebrovascular disease, cystic fibrosis, hypertension/high blood pressure, immunocompromised state, neurologic conditions, liver disease, pulmonary fibrosis, blood disorder).

Phase 1B - Persons age 65 and older with or without high-risk medical conditions.

Phase 1B - Persons with two or more *high-risk medical conditions regardless of age. (*Cancer, chronic kidney disease, COPD, Down Syndrome, heart conditions, organ transplant, obesity/severe obesity, pregnancy, sickle cell disease, smoker, diabetes, asthma, cerebrovascular disease, cystic fibrosis, hypertension/high blood pressure, immunocompromised state, neurologic conditions, liver disease, pulmonary fibrosis, blood disorder).

Phase 1B - Child care workers.

Phase 1B - Workers employed by preschools or Kindergarten through 12th grade: Teachers, nutritional services, aides, bus drivers, principals, administrative staff, custodians, etc.

None of the above - Not eligible for vaccine at this time.

PHASE 1A/1B COVID-19 VACCINATION INTEREST SURVEY

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

Question Title

* 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)

Question Title

* 2. Date of Birth:

Question Title

* 3. Age:

Question Title

* 4. What priority group do you fit into?

Question Title

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