COVID-19 Interest Form

Grundy County Health Department

COVID-19 Vaccine Interest & Notification Survey
Grundy County Health Department will use the information you provide to notify you of COVID-19 vaccine clinics. When you complete this form, you are giving permission for GCHD to contact you by phone or email.

Completion of this form does not ensure a vaccination or prioritization for any person. This information will be used for notification and planning purposes only.

Prioritization of vaccinations are determined by the Centers for Disease Control, and Missouri Department of Health and Senior Services.
Name

First Name Last Name
Are You a Grundy County Resident?

Yes No
Age
Priority Group

Phase 1A (Long term care staff and residents, healthcare workers) Phase 1B Tier 1 (Law enforcement, fire, corrections) Phase 1B Tier 2 (over 65) Phase 1B Tier 2 (under 65 with health conditions that make you eligible) Phase 1B Tier 3 (educators K-12, childcare, critical infrastructure) Phase 2 (higher education, critical infrastructure) Phase 3 (remaining unvaccinated)
Missouri Priority Group Listing Available Here
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email
example@example.com
Should be Empty:

Grundy County Health Department