COVID-19 Vaccine 1c Distribution Screening
This form is for individuals to receive vaccine in 1c distribution. Those eligible in phase 1c include People ages 65-74, People aged 16-64 with high risk conditions causing increased risk for severe disease, Essential workers in these sectors:• Transportation and logistics• Water and wastewater• Food service• Housing construction• Finance, including bank tellers• Information technology• Communications• Energy, including nuclear reactors• Legal services• Federal, state, county and local government workers, including county election workers, elected officials and members of the judiciary and their staff• Media• Public safety• Public health workers. Once this form is submitted, a member of our team will review the request. You will receive an email link to schedule your vaccine from COVID@hartzells.com once eligibility is confirmed AND vaccine is available. Please do not call the pharmacy to follow up on requests. We will only schedule appointments for the number of doses we receive from the Department of Health when we are able to provide 1c vaccine. Requests will be processed in the order received with priority to 1a and 1b requests.
Which of the following applies to you? If none of these apply, you are not eligible to receive the vaccine at this time. Please check back at a later date.
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Age 65-74
Age 18-64 with high risk conditions
Other essential worker (as described above)
If you are a healthcare or other essential worker, what is your place of employment?
What is your position?
Name
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First Name
Last Name
Birthdate
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-
Month
-
Day
Year
Date
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Submit
Should be Empty: