Covid-19 Vaccine
ALL MISSOURI RESIDENTS ARE WELCOME TO COMPLETE THIS SURVEY, IT IS NOT LIMITED TO POLK COUNTY. We are collecting the following information for those interested in receiving the Covid-19 vaccine. This does NOT register you for an appointment, however this provides us with the information to contact you when when appointments become available for your phase.
Name
*
First Name
Last Name
Date of Birth:
*
/
Month
/
Day
Year
Age:
*
Phone Number:
*
Email:
*
If no email, type N/A
Race:
*
African American
American Indian
Asian
White/Caucasian
Hispanic
Native Hawaiian/Other Pacific Islander
Prefer not to answer
Address:
*
Street Address Line 2
Please Select
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County
*
Place of Employment
*
If no employment, type N/A
College Student
Please list College or University if you currently attend
Are you one of the following?
*
Phase 1A: First Responder, Healthcare Worker, Long Term Care
Phase 1B Tier 1: Public Health, Law Enforcement, Public Works, Emergency Management, Emergency Services
Phase 1B, Tier 2: Adult with chronic condition
Phase 1B Tier 2: Anyone age 65 or older
Phase 1B Tier 3: Essential Worker; Education (K-12), Communication, Childcare, Food and Agriculture (convenient and grocery stores, not restaurants or fast food), Energy and Dams Sector, Government (elected officials), and IT services (More info https://covidvaccine.mo.gov/priority/Phase1b/)
Phase 2: Equity and Economic Recovery; Chemical Sector, Commercial Facilities, Critical Manufacturing, Defense Industrial Base Sector, Financial Services, Food and Agriculture (includes restaurants and fast food), Government personnel, Higher Education, Disproportionately Affected Populations, Homeless
Unsure of my Phase or Category
Preferred time to receive vaccine at the Polk County Health Center
8am- 12pm
1pm-5pm
After 5pm
Anytime
Submit
Should be Empty: