Henry County, OH Phase 1a Scheduling List

If your organization is on the State of Ohio Phase 1a Prioritization List, please complete this form to be placed on our vaccination interest list. As we receive more doses, we will work with you to inform you of the location, time and method of registration for your staff. At this time, we do not have exact dates and timeframes because it all hinges on when and how much vaccine we receive from the state. Once more information becomes available you will be notified, so please be patient.

Please do not submit your information more than once.

You can view the priority list on this document: https://coronavirus.ohio.gov/static/vaccine/general_fact_sheet.pdf.

Question Title

* 1. Provider Type

Home health/hospice workers

EMS Responders

Primary care providers

Free-standing emergency department, urgent care, pharmacy, and dialysis center providers not vaccinated by hospitals or healthcare systems

Dental providers

Mobile unit practitioners

Federally-qualified health center providers

High-risk ancillary health care staff members

OB-GYN practitioners

Healthcare providers, including public health employees, at risk for exposure (ex: vaccinators)

Other (please specify)

Question Title

* 2. Agency/Organization Name

Question Title

* 3. Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Henry County, OH Phase 1a Scheduling List

Question Title

* 1. Provider Type

Question Title

* 2. Agency/Organization Name

Question Title

* 3. Address

Question Title

* 4. Estimated Number of Staff to Receive Vaccine.

Question Title

* 5. Contact Name

Question Title

* 6. Contact Phone Number

Question Title

* 7. Contact Email