Geary County COVID-19 Vaccination Roster Request

Geary County Health Department intends to use this form to identify individuals who would like to receive the COVID-19 vaccine and to know your phase of distribution. To determine what phase you are in, please visit the website below.

After the survey, a Geary County Health Department representative will call to schedule your vaccination once your phase starts. (This may be greater than a month)

Updates on the current phase will be available on Geary County’s website.

For more information about the vaccine distribution, please visit:

https://www.coronavirus.kdheks.gov/DocumentCenter/View/1533/COVID-19-Vaccination-Plan-for-Kansas-Version12-1142020?bidId=

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Birth Date

MonthDayYear

Are you 65 years of age or older?

YesNo

Are you employed?

YesNo

Are you employed by a school?

YesNo

Which school?

Who are you employed by?

Have you tested positive for COVID-19 in the last three months?

YesNo

Are you healthcare personnel paid or unpaid, who is likely to be exposed to or treat people with COVID-19 or infectious materials and are unable to work from home?

YesNo

Are you a person who is at increased risk for severe illness from COVID-19, including those with under lying medical conditions such as cancer, chronic kidney disease, chronic obstructive pulmonary disease, heart conditions, obesity, sickle cell disease, smokers or those with a history of smoking, and type 2 diabetes?

YesNo

Do you work in any of the following sectors? Chemical, Commercial Facilities, Communications, Critical Manufacturing, Dams, Defense Industrial Base, Emergency Services, Energy, Financial Services, Food and Agriculture, Government Facilities, Healthcare and Public Health, Information Technology, Nuclear Reactors, Materials, and Waste, Transportation Systems, Water and Wastewater Systems

YesNo

Are you a long-term care resident?

YesNo

How would you prefer to receive your vaccination?

Drive-throughWalk-throughDoesn't matter

Are you unable to leave your home and considered homebound?

YesNo