Form

Houston County

COVID-19 Vaccine Interest and Screening Form

Please complete this form if you would like to be notified when your COVID-19 vaccination can be scheduled in Houston County. Scheduling your vaccination will depend on identified priority groups and available vaccine supply. We cannot guarantee when you will be scheduled for the COVID-19 vaccine. This form is a way to identify and communicate with individuals in the various priority groups; this is just the first step in identifying those that qualify. This form should be completed only one time and it may take some time before an appointment can be scheduled. Those not currently eligible for the vaccine will be able to provide contact information for the Health Department to contact you when we move to additional phases.

Houston County Public Health and Human Services continue to receive a high volume of calls and ask that people who complete the Vaccine Interest and Screening Form do not send multiple messages or phone calls.

The type of vaccine currently available in Houston County is Moderna. It is available to those age 18 and over. Moderna is given in a 2 dose series; you must commit to receiving the 2nd dose in order to receive the 1st dose. Note: If you have any history of severe allergies to vaccines, you should discuss the COVID-19 vaccine with your healthcare provider.

If you have questions about this form, please contact us at Houston County Public Health & Human Services at phn@co.houston.mn.us

Thank you for your patience!
Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Home Phone Number: *
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
Email: *
example@example.com
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please indicate to which priority group(s) you belong: *

Emergency medical services personnel Dental office staff Pharmacy staff Chiropractic office staff Group home resident Group home staff Pre-K - 12 educator Other school staff, i.e. classroom aide, food service, etc. Licensed/certified child care program staff Mental/behavioral health setting staff Correctional setting 65 years and older 55-64 years old 18-54 years old Mortician and/or funeral home director Long-term care facility staff Long-term care facility resident Home care agency staff Healthcare personnel in clinic Healthcare personnel in hospital Underlying medical or chronic health condition Food/Agricultural Worker Manufacturing Worker Grocery Store Worker Transportation Worker Food Service Worker Construction Worker Finance/Banking Worker IT/Communications Worker Energy Worker U.S. Postal Service Worker Local Government Worker (city, county) Law Office/Legal Staff Public Safety Worker Media Outlet Worker Other
List any underlying medical or chronic health conditions:
Other:
If you belong to a priority group not listed above, please note here.
Should be Empty: