Clinton County, IL Health Department COVID-19 Vaccine Registry

Clinton County, IL Health Department COVID-19 Vaccine Registry
The Clinton County Health Department COVID-19 Vaccine Registry will be used to inform community partners and the general public of important updates and scheduling related to the COVID-19 Vaccine availability in Clinton County. This includes the status of COVID-19 vaccination efforts. A representative of the Health Department will contact you by phone regarding COVID-19 vaccination opportunities and scheduling based on your identified employment category (e.g., healthcare). Please note: completion of this form is not scheduling you an appointment for the COVID-19 vaccine.
- The Clinton County Health Department and Illinois Department of Public Health are working to prioritize vaccinations in alignment with the recommendations from the CDC’s Advisory Committee on Immunization Practices (ACIP).
- Vaccination is by appointment only and dependent on vaccine supply.
- Vaccination prioritization will continue to change as COVID-19 vaccine supply increases in the coming weeks.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Age *
Phone Number *
Please enter a valid phone number.
Email
example@example.com
Do you live and/or work in Clinton County, IL? (At this time, we are only registering Clinton County residents or employees of Clinton County businesses) *

I live and work in Clinton County, IL. I live in Clinton County, IL but do not work in the county. I work in Clinton County, IL but do not live in the county.
Please share the city/town you live and/or work in Clinton County. *
Please select which category best suits you or your organization/agency: *
Describe what underlying condition or comorbidity qualifies you to receive the COVID-19 Vaccine *
Organization/ Agency Name: *
Position/Title: *
Notes from call (please include detailed notes & your initials)
Should be Empty: