The Chase County Health Department would like for Chase County residents to complete the survey below to help identify individuals who would like to receive the COVID-19 vaccine.  Please note that participation in this survey is completely voluntary and your personal information will not be shared. 

The Chase County Health Department is following the Kansas Department of Health and Environment’s vaccination plan and it’s tiered approach to vaccinating our populations.  To determine what phase you are in, please visit the website below.

https://www.coronavirus.kdheks.gov/284/COVID-19-Vaccine

After the survey, a Chase County Health Department representative will call to schedule your vaccination, once your phase starts. 

If your employer has surveyed you regarding your interest in the vaccine or you have already called the health department to be placed on the wait list, please do not complete this survey.

If you do not feel comfortable completing this survey online, please contact the Chase County Health Department at 620-273-6377 to provide your information.   

For general COVID 19 information please visit:   https://www.coronavirus.kdheks.gov/1/Home

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* 1. First and last name

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* 2. Address

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* 3. Are you 75 years of age or older

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* 4. Are you 65 years of age or older

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* 5. Are you employed?  If so, what is your profession?

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* 6. Have you tested positive for COVID 19 in the past 90 days?

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* 7. Do you have any of the following health conditions:  Cancer, Chronic Kidney disease, COPD, heart conditions, obesity, sickle cell disease, smoker or history of smoking, or type 2 diabetes?

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* 8. Comments or questions for health department staff

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