Vaccine Request Form

Ellis County Health Department

COVID-19 Vaccine Request Form
- Ellis County Health Department (ECHD) is notified on Wednesdays of how many doses we are to receive the following week.
- ECHD will utilize the vaccine registration form to determine which individuals meet the current criteria for vaccination and provide this information to First Care Clinic to schedule appointments for vaccination.
- Individuals will receive a text message or an email with a time and date of vaccination. This email or text will come from firstcareclinic@ustartcheckin.com .
- At this time for the purpose of timely administration all vaccines will be administered at our Mass Vaccination Site. We have partnered with First Care Clinic, HaysMed, part of the University of Kansas Health Systems and Big Creek Crossing to open a large-scale vaccination clinic located in the old Gordmans Building on the north end of Big Creek Crossing Mall at 2918 Vine St. Hays, KS 67601.
Vaccine Prioritization:

https://www.kansasvaccine.gov/DocumentCenter/View/121/Vaccine-Prioritization-Slides-PDF
Name *

First Name Last Name Suffix
Mobile Phone:

Area Code Phone Number
Can you receive and reply to text messages at this number?

Yes No
Home Phone: *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date *

MM DD YYYY
Email
example@example.com
Do you live or work in ELLIS COUNTY? (KANSAS) *

Yes No
Are you 65 years of age or older? *

Yes No
Age: *
Have you tested positive for COVID-19 in the last 3 months? *

Yes No
Are you a 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? *

Yes No
Do you currently reside in a congregate setting? (i.e. facilities that are licensed by the state or local government, that provide housing or care arrangements and where social distancing is not possible; they provide a form of social service, healthcare, or healthcare-associated service) *

Yes No
View: Congregate Settings- Page 6
Are you a person who is at increased risk for severe illness from COVID-19, including those with underlying 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, type 2 diabetes, or immunocompromised? *

Yes No
Are you a high-contact critical worker as defined by the Dept. of Homeland Security? (i.e. workers that are necessary to maintain systems, assets and activities that are vital to the state (or national) security, the economy, or public health.)

Examples of these are:
- Firefighters
- Police officers
- Grocery store workers
- K-12/ higher ed. staff and childcare workers
- Transportation workers
- Retail, warehouses/sales outlets
- Agriculture
- Supply of critical services/materials for the COVID response (e.g. PPE)
- U.S. Postal Service
- Department of Motor Vehicles.
View: High-Contact Critical Workers- Page 5
High-Contact Critical Worker? *

Yes No
Today's Date *

Month Day Year
Should be Empty:

Ellis County Health Department