LIVE - Screening for COVID-19 Vaccination

COVID-19 Vaccine Screening and Interest Form
Thank you for your desire to slow COVID-19 by requesting a vaccine! All individuals interested in receiving a COVID-19 vaccination should complete this form. Those who complete the form who are not yet eligible to receive a vaccine will be contacted once they become eligible. Please do NOT complete multiple forms for the same person.

The following provides an overview of who is currently eligible to receive a vaccination and those who will likely be eligible in the next phase. This list will be updated as things change in our community.

CURRENTLY: The State of Wisconsin allows vaccinators in Wisconsin to vaccinate the following populations:
- Frontline healthcare workers (Please note: the definition of "frontline healthcare worker" is defined by the state of Wisconsin to include some professions outside of providers; please check the full list here)
- Residents (and staff) of longterm care facilities
- Individuals 65 and older
- Law enforcement, firefighters, correctional facility personnel, probation and parole officers, and DNR wardens
COMING SOON: The next phase of eligible individuals will tentatively being on March 1, 2021 (subject to change with input from State DHS). Eligible categories include:
- Individuals who work in one of the following settings:
  - Educators and child care providers
    
    All staff in regulated child care, public and private school programs, out-of-school time programs, virtual learning support, and community learning center programs.
    
    All staff in Boys and Girls Clubs and YMCAs.
    
    All staff in preschool and Head Start through K-12 education settings.
    
    Faculty and staff in higher education settings who have direct student contact.
  - 911 providers
  - Utility and communication providers
    
    Specifically, workers who cannot socially distance and are responsible for the fundamental processes and facilities that ensure electric, natural gas, steam, water, wastewater, internet, and telecommunications services are built, maintained, generated, distributed, and delivered to customers)
  - Public transit
    
    Defined as drivers who have frequent close contact with members of the public, limited to: public and commercial intercity bus transportation services, municipal public transit services, those employed by specialized transit services for seniors, disabled persons, and low-income persons; does not include individuals in ride share or those providing services like Uber)
  - Food Supply Chain
    
    Agricultural production workers, such as farm owners and other farm employees.
    
    Critical workers who provide on-site support to multiple agricultural operations, such as livestock breeding and insemination providers, farm labor contractors, crop support providers, and livestock veterinarians.
    
    Food production workers, such as dairy plant employees, fruit and vegetable processing plant employees, and animal slaughtering and processing employees.
    
    Retail food workers, such as employees at grocery stores, convenience stores, and gas stations that also sell groceries.
    
    Hunger relief personnel, including people involved in charitable food distribution, community food and housing providers, social services employees who are involved in food distribution, and emergency relief workers.
  - Non-frontline essential health care personnel : staff members who are not involved in direct patient care but are essential for health system infrastructure; they are often affiliated with hospitals, but non-hospital employee non-frontline employees are also included.
    
    Public health
    
    Emergency management
    
    Cyber security
    
    Health care critical supply chain functions, including the production, manufacturing, and distribution of vaccine
    
    Support roles, such as cleaning, HVAC, and refrigeration, critical to health system function
- Individuals who live or work in certain other environments, as follows:
  - Individuals Enrolled in Medicaid Long-Term Care Programs
    
    Members of Family Care and Family Care Partnership and participants in IRIS : Family Care members and IRIS participants often have underlying conditions that make them more vulnerable to COVID-19.
    
    Participants in Wisconsin’s Children’s Long-Term Support Waiver and Katie Beckett programs are likewise eligible if they meet age requirements for the vaccine.
  - Congregate Living Facility Staff and Residents: Individuals who live or work in congregate settings such as the following and who do NOT have the ability to work with the pharmacy partnership program
    
    Employer-based housing : Housing provided by an employer for three or more unrelated individuals that share bedrooms.
    
    Housing serving the elderly or people with disabilities : Residents of housing that meets the definitions of an adult family home, independent living apartments, community-based residential facility, residential care complex, state center for the disabled, mental health institute, and county-based center for the disabled
    
    Shelters : Shelter provided to those who are homeless and/or in need of protection (for example, domestic violence shelters).
    
    Transitional housing : A project that is designed to provide housing and appropriate supportive services to homeless persons to facilitate movement to independent living when such facilities include shared bedrooms.
    
    Incarcerated individuals : Individuals in jails, prisons, and mental health institutes.
PLEASE NOTE: It may be necessary to prioritize people within each phase depending on vaccine supply. For this reason, the timing of your vaccine eligibility is dependent on many factors, including state-set policies that local health departments and providers are asked to adhere to closely.

We want to ensure that everyone who can and wants to be vaccinated is able to access a COVID-19 vaccine as soon as possible. You will be contacted by the appropriate vaccinating entitiy to schedule an appointment as soon as you meet eligibility criteria. You will not receive follow-up communication from La Crosse County Health Department.

Please enter your age. *

Please select if you belong to one of the groups below. Most are related to occupations. There is one choice that is not related to occupations, which is "individuals enrolled in Medicaid long-term care programs." If you are not an individual enrolled in a Medicaid long-term care program, and you either are not currently employed (retired, in school, unemployed) or do not see your occupation below, please select "none of the above." *
Note: "Educators and child care" is defined by DHS to include the following:
- All staff in regulated child care, public and private school programs, out-of-school time programs, virtual learning support, and community learning center programs.
- All staff in Boys and Girls Clubs and YMCAs.
- All staff in preschool and Head Start through K-12 education settings.
- Faculty and staff in higher education settings who have direct student contact .
If you work for one of the following entities, please select your employer. If you do not see your employer, please select "other." *

Kwik Trip University of Wisconsin - La Crosse (UWL) Viterbo La Crosse County (any affiliated agency) Neighborhood Family Clinic Gundersen Health System Mayo Clinic Health System - La Crosse Other
Please specify your employer (other): *
What is the name of your employer? Please be specific (i.e. if you are a teacher, please list the name of the school where you teach; if you work for a healthcare agency, please list the name/branch of the agency you work for).

Where do you receive your primary medical care? *

Gundersen Health System Mayo Clinic Health System I do not have a primary care provider Other
Specify primary care provider (other):
Have you seen your primary care provider at the healthcare institution you selected in the past 3 years? *

Yes No I don't know

Based on answers to the previous questions, you have the option to be vaccinated through your healthcare system. Do you want to be vaccinated through your primary care location once available, or would you prefer to go through a different vaccinator? *

Yes, I prefer being vaccinated through my primary healthcare system No, I do NOT want to be vaccinated through my primary healthcare system and request to be sent to another vaccinator if available
Based on answers to the previous questions, you have the option to be vaccinated through your healthcare system provider OR through your employer. Do you want to be vaccinated through your primary care location once available, or would you prefer to go through your employer?

I prefer being vaccinated through my primary healthcare system I prefer being vaccinated through my employer

NOTE: By submitting this form, you agree that all information provided is true and accurate to the best of your ability.

Important: Please read and print the information after you hit submit for instructions on the next steps. If you have any questions, please contact covid19@lacrossecounty.org.
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COVID-19 Vaccine Screening and Interest Form

You are eligible to register NOW. Complete this form.

You will be eligible for vaccination soon. Complete this form now so we can connect you with a vaccinator when possible.

You are not eligible for COVID-19 vaccination at this time. Please complete this form so we can connect you with a vaccinator once additional groups are eligible for vaccination.