Cooke County Coronavirus Vaccination Request Form

1
In which county do you reside?* This field is required.Please visit the DSHS website to find vaccine providers near your location.
2
This vaccination will be my:* This field is required.To ensure safety and full treatment, we must remain consistent with the brand of vaccine each individual receives.
First Dose
Second Dose
3
What brand of vaccine was your initial dose?* This field is required.To ensure safety and full treatment, we must remain consistent with the brand of vaccine each individual receives.
Pfizer
Moderna
Other
4
General Information* This field is required.
First Name
Middle Name
Last Name
5
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Cooke County Emergency Management requires information to contact you about the next steps in the registration process, clinic times, and locations.
Double-check the information in the next section because if it is incorrect we will not be able to reach you about vaccination availability.
7
Cell Phone Number* This field is required.Please enter a cell phone number so that we may send you text message notifications about the next steps in the registration process. To keep everything orderly, we will only be sending text message notifications to these phone numbers, so please ensure your information is correct. If submitting the form for several different people, you MAY use the same phone number for each person if necessary.
8
Email Address* This field is required.Please enter an email address that you check every day so that we may email you about the next steps in the registration process. If submitting the form for several different people, you MAY use the same email address for each person, if necessary.
johndoe@example.com
Confirm Email
9
The information in the next section determines if you fall into any of the priority groups for vaccination. It also helps us to know who is getting vaccinated and who still needs to be vaccinated.

All required fields give you the option to select refuse to answer as a choice; however, that may impact our ability to determine your eligibility. Gender, Race, and Ethnicity, however, are required for reporting vaccines administered.
10
Date of Birth* This field is required.
Date of Birth
Month
Day
Year
11
Gender, Race, Ethnicity* This field is required.These fields are required for reporting vaccines administered.
Male
Female
Non-binary
Refuse to Answer
Gender
White
Black
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Other/Mixed
Refuse to Answer
Race
Non Hispanic/Latino
Hispanic/Latino
Refuse to Answer
Ethnicity
12
Do you meet the eligibility criteria outlined in category 1A?* This field is required.In Phase 1A front-line healthcare workers or residents of a long-term care facility are eligible to receive the vaccine. If you do not know if you meet eligibility, refer to the information here.
YESNO
13
Do you meet the eligibility criteria outlined in category 1B?* This field is required.If you are in Phase 1B, you may also be eligible to get the COVID-19 vaccine, depending on availability and the vaccine provider. Vaccine supply remains limited, but more vaccine doses will be delivered to providers each week. If you do not know if you meet eligibility, refer to the information here.
YESNO
14
We are only accepting registrations from people who fall into category 1A or 1B at this time. It is urgent that we get vaccines to the most at-risk populations right now. Please check back later to see if this has changed.

If you need to change your answers, click the "Previous" button below.
15
Do you have an Underlying Medical Condition?An underlying condition is a health condition that you have that makes you more likely to get sick. In most cases, it is a condition for which you receive ongoing treatment. Underlying conditions also make you more likely to get severely ill if you get COVID-19. Underlying conditions typically require routine medical visits so the condition can be monitored by a healthcare provider and/or treated with one or more. Adults of any age with the following conditions are at increased risk of severe illness from the virus that causes COVID-19: Cancer, Chronic kidney disease, COPD (chronic obstructive pulmonary disease), Down Syndrome, Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies, Immunocompromised state (weakened immune system) from solid organ transplant, Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2), Severe Obesity (BMI ≥ 40 kg/m2)Pregnancy, Sickle cell disease, Smoking, Type 2 diabetes mellitus COVID-19 is a new disease. Currently, there is limited data and information about the impact of many underlying medical conditions on the risk of severe illness from COVID-19. Based on what we know at this time, adults of any age with the following conditions might be at an increased risk for severe illness from the virus that causes COVID-19: Asthma (moderate-to-severe),Cerebrovascular disease (affects blood vessels and blood supply to the brain), Cystic fibrosis,Hypertension or high blood pressure,Immunocompromised state (weakened immune system) from blood or bone marrow transplant,immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines, Neurologic conditions such as dementia, Liver disease, Overweight (BMI > 25 kg/m2, but < 30 kg/m2),Pulmonary fibrosis (having damaged or scarred lung tissues), Thalassemia (a type of blood disorder), Type 1 diabetes mellitus
Yes
No
Refuse to answer
Unknown
16
I agree that the information that I have provided may be released and exchanged with other healthcare providers that are giving COVID-19 vaccines.* This field is required.Review submission of information so that we may have accurate data.
YESNO
17
Today's DateConfirm today's date for an accurate timeline of applicants.
Date
Month
Day
Year
18
Confirmation code. Keep this code by writing it down or taking a picture of it with your phone. We will ask for this as a security identifier if you decide you need to be taken off of the waitlist for any reason.
Should be Empty:

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.