Screening for COVID-19 Vaccination - 2/5/21 Rollout (English)

COVID-19 Vaccine Screening and Interest Form
Thank you for your desire to slow COVID-19 by requesting a vaccine! Individuals interested in receiving a COVID-19 vaccination who are in the current or next eligible groups should complete this form. Please do NOT complete multiple forms for the same person. If you have already spoken to someone at the Trempealeau County Health Department, Gundersen Tri-County, or Mayo Clinic regarding vaccine screening, please do NOT complete this form. If you already have a plan to receive the vaccine elsewhere, please do NOT complete this form.

The following provides an overview the current and next eligible groups to receive a vaccination. Please refer to the Wisconsin Department of Health Services for more details of each group.

CURRENTLY ELIGIBLE GROUPS:
- Frontline healthcare workers
- Law enforcement, fire, and correctional personnel
- Coroners, medical examiners, and funeral staff
- Individuals age 65 and older
- Direct care personnel , for example, people who provide direct care to patients, including in their homes (for example, personal care assistant; home health worker; adult day service providers; paid and unpaid caregivers in Family Care, Family Care Partnership, and IRIS; paid and unpaid caregivers of children in special needs programs, including Children’s Waivers, CCOP, B3, Children with Medical Complexity, CCF WAM and Katie Beckett Medicaid)
NEXT ELIGIBLE GROUPS (in order of priority):
- Education and regulated child care
- Individuals enrolled in Medicaid long-term care programs
- Some public-facing essential workers (911 operators, public transit, utility and communications, food supply chain)
- Non-frontline essential healthcare personnel
- Congregate living facility staff and residents
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 required 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 and appointments/vaccine are available.

Please enter your age. *

Select your occupation/group below. If you are not currently employed (retired, in school, unemployed) or do not see your occupation/group below, please select "none of the above." *
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). *
What is your position? Please be specific. *

You are eligible to register NOW. Complete this form.
Your answers indicate you are eligible to register for vaccination. This is NOT an appointment to get the vaccine, but to be connected with a vaccinator who will eventually schedule your appointment. NOTE: This may take several weeks. Do NOT contact the health department to ask about the status, as a large influx of calls will delay our ability to roll-out vaccine.

Due to vaccine supply, we may need to further prioritize individuals based on current vaccine supply and/or based on WI Department of Health Services guidance. Once a vaccine is available for you, the Trempealeau County Health Department will forward your information directly to a local vaccination provider who will contact you to schedule your COVID-19 vaccination.

Trempealeau County vaccinators are using vaccines from both Pfizer and Moderna. These vaccines have been rigorously tested and are considered safe and effective for most people. Both types of vaccines are given in a 2 dose series, 21 or 28 days apart depending on the vaccine given. You must commit to receiving the 2nd dose in order to receive the 1st dose. Before you receive the COVID-19 vaccine, your provider will share information about the vaccine and instructions for what do to after you receive the vaccine. Total appointment time is approximately 30 minutes. Note: If you have any history of severe allergies to vaccines, you should discuss the COVID-19 vaccine with your personal medical provider.

Before you are vaccinated, you will be asked to respond to the following:

In the past 14 days:
1. Have you tested positive for COVID-19?
2. Have you experienced any of the following COVID-19 symptoms?
  - Fever or chills
  - Cough
  - Shortness of breath/difficulty breathing
  - Fatigue
  - Muscle or body aches
  - Headache
  - New loss of taste or smell
  - Sore throat
  - Congestion or runny hose
  - Nausea or vomiting
  - Diarrhea
3. Have you received any vaccine/immunizations?
If you answer yes to any of the above questions, you will not be able to receive the COVID-19 vaccine and should wait 14 days before filling out this form.

If you have any questions about this form, please contact us at the Trempealeau County Health Department at tchealth@co.trempealeau.wi.us.
Full Name: *

First Name Middle Name Last Name
Date of Birth: *

Month Day Year
Date
Personal Phone Number: *
Please enter a valid phone number.
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please enter your email address. If you do not have one, type N/A. *
Where do you receive your medical care? (Note: you may be contacted by a different provider, but answering this question will help us streamline appointments) *

Gundersen Health System Mayo Clinic Health System Other/None

You will be eligible for vaccination soon. Complete this form now so we can connect you with a vaccinator when possible.
Your answers indicate you will soon be eligible for vaccination. Due to vaccine supply, we may need to further prioritize individuals based on current vaccine supply and/or based on WI Department of Health Services guidance.

Once vaccine is available and you are actively eligible to schedule an appointment, the Trempealeau County Health Department will forward your information directly to a local healthcare provider who will contact you to schedule your COVID-19 vaccination. NOTE: This may take several weeks. Do NOT contact the health department to ask about the status, as a large influx of calls will delay our ability to roll-out vaccine.

Trempealeau County vaccinators are using vaccines from both Pfizer and Moderna. These vaccines have been rigorously tested and are considered safe and effective for most people. Both types of vaccines are given in a 2 dose series, 21 or 28 days apart depending on the vaccine given. You must commit to receiving the 2nd dose in order to receive the 1st dose. Before you receive the COVID-19 vaccine, your provider will share information about the vaccine and instructions for what do to after you receive the vaccine. Total appointment time is approximately 30 minutes. Note: If you have any history of severe allergies to vaccines, you should discuss the COVID-19 vaccine with your personal medical provider.

Before you are vaccinated, you will be asked to respond to the following:

In the past 14 days:
1. Have you tested positive for COVID-19?
2. Have you experienced any of the following COVID-19 symptoms?
  - Fever or chills
  - Cough
  - Shortness of breath/difficulty breathing
  - Fatigue
  - Muscle or body aches
  - Headache
  - New loss of taste or smell
  - Sore throat
  - Congestion or runny hose
  - Nausea or vomiting
  - Diarrhea
3. Have you received any vaccine/immunizations?
If you answer yes to any of the above questions, you will not be able to receive the COVID-19 vaccine and should wait 14 days before filling out this form.

If you have any questions about this form, please contact us at the Trempealeau County Health Department at tchealth@co.trempealeau.wi.us.
Full Name: *

First Name Middle Name Last Name
Date of Birth: *

Month Day Year
Date
Personal Phone Number: *
Please enter a valid phone number.
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please enter your email address. If you do not have one, type N/A. *
Where do you receive your medical care? (Note: you may be contacted by a different provider, but answering this question will help us streamline appointments) *

Gundersen Health System Mayo Clinic Health System Other/None

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 tchealth@co.trempealeau.wi.us
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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.