COVID-19 Vaccine Eligibility Form
The following questions will help us determine if you are eligible to receive the vaccine. If you do not qualify, do not worry. You will become eligible in the future as we move forward. Lyon County Public Health is working to vaccinate individuals by risk severity. If you are unsure of a question, please reach out to public health or your healthcare provider.
Name*
First Name Last Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Select the option that best represents you, otherwise select "none of the above". (Another section will appear after selecting "none of the above")*
Healthcare worker Resident or patient in Long-term care (LTC), senior housing or LTC-supported independent living Worker critical to pandemic response continuity Home care worker, CMS-designated caretaker Mortician, forensic or funeral service worker Healthcare-associated contractor, including food, waste management etc. Veterinarian Journalist that is not able to work from home Aged 65 and older None of the above
Select the option that best represents you, otherwise select "none of the above". (Another section will appear after selecting "none of the above")
High-contact critical worker Firefighter, police officer, first responder or correction officer K-12 worker, includes teachers, custodians, drivers or other staff Childcare worker Food processing worker Food service worker, including grocery store workers Large-scale manufacturing plant worker Transportation worker Retail, warehouse or sales worker Postal service worker None of the above
Select the option that best represents you, otherwise select "none of the above". (Another section will appear after selecting "none of the above")
Licensed congretate facility resident or staff Homeless shelter resident or staff Childcare institution participant or staff, including adult or child protective services Shelter, safe house resident or staff Correction facility resident or staff Behavioral health institution participant or staff Retirement facility resident or staff Home care giver, personal care aide Senior living home resident or staff Person aged 65+ None of the above
Select the option that best represents you, otherwise select "none of the above". (Another section will appear after selecting "none of the above")
Person aged 16-64 with severe medical risks Cancer patient Chronic kidney disease patient Chronic obstructuve pulmonary disease patient Down syndrome individual Patient with a heart condition Type 2 diabetes mellitus patient Sickle cell disease patient Pregnant patient Immunocompromised state from solid organ transplant individual None of the above
Select the option that best represents you, otherwise select "none of the above". (Another section will appear after selecting "none of the above")
Non-healthcare worker in critical infrastructure Other agricultural or food worker Utility workers Other social service or government worker Logistics worker, such as truck transportation, couriers and others. Water or wastewater worker Shelter and housing worker Finance worker, such as bank tellers Information technology and communications worker None of the above
Select the option that best represents you, otherwise select "none of the above".
Aged 16-64 with other medial risks Asthma patient Cerebrovascular disease patient Cystic fibrosis patient Immunocompromised patient Neurologic condition patient, such as dementia Liver disease patient Pulmonary fibrosis patient Thalassemia patient Type 1 diabetes mellitus patient Obese or severely obese patient None of the above
What is your occupation?*
ex) Registered nurse, high school teacher, cashier
What is the name of your employer?*
ex) walmart, tyson, westar energy
Should be Empty: