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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 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: We are able to vaccinate the following populations:
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.
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:
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 firstname.lastname@example.org.
Thank you for your interest in the COVID-19 vaccine. At this time, you do NOT meet the eligibility requirements for vaccination. Please DO NOT fill out this form again until you are in an eligible group.
As more vaccines are available in our community, additional groups can receive them. Please check our website, Facebook page, and the Wisconsin Department of Health Services for the most up to date information regarding vaccination.
Until at least 70% of our community has completed a full vaccine regiment, please remember to wear your mask, wash your hands, stay 6 feet from others, and stay home if you have any symptoms of COVID-19.
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 email@example.com