COVID-19 Vaccine Interest Form for Individuals

COVID-19 Vaccine Interest Form for Individuals
The Lenawee County Health Department has begun vaccinating individuals against COVID-19 based on the Michigan Department of Health and Human Services priority groups.

If you are interested in receiving a vaccination, please complete the following information. Once appointments are available for your priority group, you will receive an email with instructions for how to make an appointment.
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you currently employed? *

Yes No
Occupation *
Employer *
Do you work or volunteer in a health care setting? Please select the setting where you work or volunteer.

EMS Long Term Care (staff and residents) Home Health Care Adult Foster Care (staff and residents) Dental Office Dialysis Center Mental Health Chiropractic Care Optometry Office Physical Therapy Pharmacy No, I do not work or volunteer in a health care field.
Are you employed in one of the following critical infrastructure industries? Please select the option which best describes your industry.

Law Enforcement Firefighters Department of Corrections Staff County Jail Staff Detention Facility Staff Pre-K-12 School Staff Childcare Workers Homeless Shelter Staff Adult and Child Protective Services Workers Healthcare and Public Health Food and Agriculture Energy Water and Wastewater Transportation and Logistics Public Works and Infrastructure Support Services Communications and Information Technology Essential Community or Government Operations and Essential Functions Critical Manufacturing Hazardous Materials Financial Services Chemical Defense Industrial Base US Postal Services Labs Congregate Child Care Institutions Funeral and Mortuary Services No, I am not employed in one of these industries
Do you fall into one of the Phase 1C priority groups listed below?

Yes No
Are you 75 or older? *

Yes No
Are you between the ages of 65 and 74? *

Yes No
Are you age 16-64 years old with COPD, hypertension, chronic kidney disease, heart disease, diabetes, obesity or other conditions that put you at high risk?

Yes No
Are you age 16 or older. *

Yes No
Is there anything else we should know?

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