Prescreen - Website Link

Contact Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
What type of phone number is this? *

Cell Phone Home Phone Other
May we contact you via text message? (Data and message rates may apply) *

Yes No
Email Address
example@example.com
May we contact you via email? *

Yes No

Occupation Description
The State of Missouri requires us to use certain criteria for determining when a client is eligible for vaccinations. An example is that a health care worker dealing directly with patients will be more likely to come into contact with a person with COVID-19 than an electrician or IT worker.

Please answer the following questions to help us determine eligibilitiy. Examples will be shown for each response by selecting an option.
Employer *
Occupation or job title *
Please select the option that best fits you. Selecting a choice will allow you to view examples. *

Patient Facing Health Care Workers and Long-Term Care Facility Residents and Staff, Home Health Agency employees First Responders, Emergency Services, and Public Health Infrastructure High Risk Individuals Critical Infrastructure Equity and Economic Recovery Other
Phase Definitions and Examples
Patient Facing Health Care Workers and Long-Term Care Facility Residents and Staff: Vaccinating those most vulnerable and those protecting them.
- Hospitals, Long-term care facilities and residents, including Department of Mental Health (DMH)-operated facilities.
- Home health, Hospice, Dialysis centers, Urgent care.
- Vaccinator staff and those administering COVID testing.
- Congregate community healthcare settings staff and residents, including DMH contracted settings and adult day cares.
- EMS and high-risk non-congregate healthcare, including clinics, physicians, and home care providers.
- All remaining patient-facing healthcare providers, including but not limited to health care workers in emergency shelters, dental offices, school nurses, pharmacies, public health clinics, mental/behavioral health providers, and correctional settings
First Responders, Emergency Services, and Public Health Infrastructure: Protecting those who keep us safe and help us during an emergency

Non-Patient Facing Public Health Infrastructure*:
- Administrators and staff at federal, state, or local public health agencies and other healthcare workers who carry out functions necessary to the operation of the state’s healthcare infrastructure that were not included in 1A.
  - Certain designated personnel in the following state agencies:
  - DSS
    
    All remaining DYS team members
    
    CD
    
    FSD teams who team with public (e.g. home visits)
  - DMH
    
    DBH
    
    DD
    
    Non-patient facing workers in facilities that were not vaccinated in 1A
  - OA
    
    ITSD in direct care facilities
    
    FMDC in direct care facilities
  - DHSS
    
    (DCPH-response teams, inspectors, service coordinators, vital records, WIC, nutritionists, disease interventionists, administration)
    
    DRL-surveyors, inspectors, specialists and call center(s)
    
    DSDS-investigators, aging/disability social service providers, LTC ombu
    
    SPHL- (COVID response and newborn operations)
  - Dental and Ophthalmic Laboratory Technicians
  - Medical Appliance Technicians
  - Embalmers, Crematory Operators, And Funeral Attendants
  - Morticians, Undertakers, And Funeral Arrangers
  - Medical waste handlers
  - Non-hospital based laboratory staff
  - Local public health agency staff
- First Responders*: All federal, state, and/or local first responders beyond EMS/EMTs in 1A, including law enforcement, fire services, corrections, and certain social service agencies.
  - Certain designated personnel in the following state agencies:
    
    Capitol Police
    
    MSHP
    
    SEMA
    
    Fire
    
    Alcohol Tobacco Control
    
    MONG/OTAG
    
    DOC
    
    All DOC staff assigned to work in a facility or who enter a facility through the course of their duties (DAI, DORS, DHS, OD, P&P)
    
    P&P staff who work with offenders in the community, transition centers, community centers, and residential facilities
    
    DNR
    
    Park Ranger Program
    
    MDC
    
    Protection Branch Staff
- Emergency Management and Public Works*: Federal, state, or local government employees in emergency management and public works agencies, identified nonprofit organizations designated as partner voluntary agencies.This category includes but is not limited to:
  Certain designated personnel in the following state agencies:
  - DNR
    
    Environmental Emergency Response (EER) & Chemical Analyses Lab
    
    Emergency State Functions Teams (ESF3, ESF10, ESF 12 support) & Deployable Regional Office/Geology Staff - Disaster Response
  - MODOT
    
    Maintenance Division
    
    Highway Safety and Traffic Division
    
    Safety and Emergency Management Unit
  - American Red Cross
  - AmeriCorps St. Louis
  - Brethren Disaster Ministries
  - Catholic Charities of Central & Northern Missouri
  - Catholic Charities of Kansas City
  - Catholic Charities of Southern Missouri
  - Catholic Charities of St. Louis
  - Convoy of Hope
  - ELCA Central States Synod and Lutheran Family and Children
  - Feeding Missouri
  - HOPE Animal Assisted Crisis Response
  - Humane Society of Missouri
  - Missouri Baptist Disaster Relief
  - MO. Adventist Community Services Disaster Response (MOACSDR)
  - Team Rubicon
  - The Salvation Army - Midland Division STL
  - The Salvation Army - Midland Division KC
  - United Methodist Church - Missouri Conference
  - University of Missouri Extension
- Emergency Services Sector: Employees defined in the emergency services sector not otherwise listed, including law enforcement, fire and rescue services, emergency medical services, emergency management, and public works.
High-Risk Individuals: Protecting those who are at increased risk for severe illness

Anyone aged 65 and older

Adults with the following conditions:
- Cancer
- Chronic Kidney Disease
- COPD (Chronic Obstructive Pulmonary Disease)
- Intellectual and/or developmental disabilities such as Down syndrome
- Heart Conditions such as heart failure, CAD (coronary artery disease) or cardiomyopathies
- Immunocompromised state from solid organ transplant
- Severe Obesity (BMI >40kg/m2)
- Pregnancy
- Sickle Cell Disease
- Diabetes (Type I or Type II)
Critical Infrastructure: Protecting those who keep the essential functions of society running

Education: Teachers, faculty, and staff in public, private, and nonprofit pre K – 12.

Childcare: Faculty and staff in a DHSS or DSS -licensed facility providing basic care to children

Communications Sector: Employees at public, private, or nonprofit organizations that provide communications services

Dams Sector: Employees at public, private, or nonprofit organizations that provide services in the dams sector related to critical water retention and control services.

Energy Sector: Employees at public, private, or nonprofit organizations that provide energy services, regardless of the energy source.

Food/Agriculture Sector – initial*: Employees of certain food production and processing facilities, andrelated operations, prioritizing mass food production, distribution, transportation, wholesale and retailsales, including grocery and convenience stores where groceries are sold; includes veterinary services. This category includes but is not limited to:
- Veterinarians, veterinary assistants and laboratory animal caretakers, veterinary technologists and technicians
- Workers at fuel ethanol facilities, biodiesel and renewable diesel facilities, and storage facilities
- Workers enabling the sale of human food, animal food (includes pet food, animal feed, and raw materials and ingredients), pet supply, and beverage products at groceries, pharmacies, convenience stores, and other retail (including unattended and vending), including staff in retail customer support and information technology support necessary for on-line orders, pickup, and delivery.
- Food manufacturer workers and their supplier workers including those employed at food ingredient production and processing facilities; aquaculture and seafood harvesting facilities; slaughter and processing facilities for livestock, poultry, and seafood; animal food manufacturing and processing facilities; human food facilities producing by-products for animal food; industrial facilities producing co-products for animal food; beverage production facilities; and the production of food packaging.
- Farmers, farm and ranch workers, and agribusiness support services, including workers involved in auction and sales; in food operations, including animal food, grain and oilseed storage, handling, processing, and distribution; in ingredient production, packaging, and distribution; in manufacturing, packaging, and distribution of veterinary drugs and biologics (e.g., vaccines); and in distribution and transport
- Farmers, farm and ranch workers, and support service and supplier workers producing food supplies and other agricultural inputs for domestic consumption and export, to include those engaged in raising, cultivating, phytosanitation, harvesting, packing, storing, or distributing to storage or to market or to a transportation mode to market any agricultural or horticultural commodity for human or animal consumption
- Workers and firms supporting the distribution of all human and animal food and beverage and ingredients used in these products, including warehouse workers, vendor-managed inventory controllers, and block chain managers.
- Workers in animal diagnostic and food testing laboratories.
- Workers of companies engaged in the production, storage, transport, and distribution of drugs and biologics (e.g. vaccines) used by the human and agricultural food and agriculture industry.
- Animal agriculture workers to include those employed in veterinary health (including those
  involved in supporting emergency veterinary or livestock services); raising, caring for and
  management of animals for food, as well as pets; animal production operations; livestock
  markets; slaughter and packing plants, manufacturers, renderers, and associated regulatory and government workforce.
- Transportation workers supporting animal agricultural industries, including movement of animal medical and reproductive supplies and materials, animal biologics (e.g., vaccines), animal drugs, animal food ingredients, animal food and bedding, live animals, and deceased animals for disposal
Government*: Elected officials in any branch of government at the state, county, and/or municipal levels required for the continuity of government; members of the judiciary at the federal, state, and/or local levels required for the continuity of government; employees designated by the federal government that fall within the state’s vaccine allocation responsibilities; other designated government personnel required for the continuity of government.This category includes but is not limited to:
- Certain designated personnel in the following state agencies:
  - All remaining DPS
  - All remaining DOC
  - OA
    
    All remaining ITSD
    
    All remaining FMDC
    
    Commissioners Office
    
    B&P
    
    GS
  - DHSS
    
    Administration/Director’s Office
    
    All remaining DCPH
    
    All remaining DRL
    
    All remaining DSDS
  - MDA
    
    Animal Health, Grain Inspection, State Milk Board, Plant Industries, Weights & Measures, Market News
  - MODOT
    
    Bridge Division
    
    Construction and Materials Division
    
    Motor Carrier Services Division
    
    General Services Division
    
    Information Services Division
  - DCI
    
    Finance and credit union examiners, PSC investigators staff, PR investigators and essential office staff, insurance essential office staff
  - DESE
    
    State Operated Schools staff
  - DHEWD
    
    Missouri Job Center Staff & Facilities Team
  - DOLIR
    
    DES: Unemployment operations & fiscal staff
  - DNR
    
    PIO Staff
    
    Dam Safety Geologic Response Engineers
    
    Division of Energy Staff - Pipeline & Weatherization
    
    Department & Division IT Managers
    
    Water Protection Program Staff (including clean water, public drinking water and financial assurance center staff)
    
    Regional Office Staff
    
    State Parks (only Certified Drinking Water & Waste Water Operators, Engineers, Environmental, Other Public-Facing Operational Staff)
    
    Environmental Services Program - sample collection & field support
  - DOR
    
    Administration Division
    
    Taxation Division
  - MDC
    
    Statewide Resource Management Branch Fish Hatchery Staff
    
    Statewide Resource Management Branch Forest Nursery Staff
- Certain designated personnel in the following federal agencies:
  - Department of Agriculture
  - Department of Commerce
  - Department of Education
  - Department of Energy
  - Department of Health and Human Services
  - Department of Housing and Urban Development
  - Department of Interior
  - Department of Justice
  - Department of Labor
  - Department of Transportation
  - Department of Treasury
  - Department of Veterans Affairs
  - Environmental Protection Agency
  - General Services Administration
  - National Aeronautics and Space Administration
  - Nuclear Regulatory Commission
  - Small Business Administration
  - U.S. Agency for International Development
Information Technology Sector: Employees at public, private, or nonprofit organizations that provide IT services.

Nuclear Reactors, Materials, and Waste Sector: Employees at public, private, or nonprofit organizations that work in this sector.

Transportation Systems Sector: Employees in the transportation systems sector including
- Aviation
- Highway and motor carriers
- Maritime transportation systems
- Mass transit and passenger rail
- Pipeline systems
- Freight rail
- Postal shipping.
Water and Wastewater Systems Sector: Employees at public, private, and/or nonprofit organizations that provide drinking or wastewater services.
Other

Protecting everyone else who has not been vaccinated, but wants to do so
Equity and Economic Recovery: Protecting those who have been disproportionately affected and accelerating economic recovery

Chemical Sector: Employees engaged in the manufacture, store, use, and transport of potentially dangerous chemicals and other diverse products in the chemical sector that are essential to modern life and economic activity.

Commercial Facilities Sector: Employees engaged in activities related to the eight subsectors within the commercial facilities sector.

Critical Manufacturing Sector: Employees in critical manufacturing engaged in the production of certain goods.

Defense Industrial Base Sector: Employees that contribute to products and services that are essential to mobilize, deploy, and sustain military operations and national defense

Financial Services Sector: Employees within the financial services sector.

Food/Agriculture Sector – remaining*: Remaining populations within the sector not included in 1B,
including restaurants.This category includes but is not limited to
- Restaurant and quick serve food operations, including dark kitchen and food prep centers, carry-out, and delivery food workers.
- Workers supporting the sanitation and pest control of all human and animal food manufacturing processes and operations from wholesale to retail.
- Workers supporting greenhouses as well as the growth and distribution of plants and associated products for home gardens.
- Workers in cafeterias used to feed workers, particularly worker populations sheltered against COVID-19 and those designated as essential critical infrastructure workers.
- Government, private, and non-governmental organizations’ workers essential for food assistance programs (including school lunch programs) and government payments.
- Workers of companies engaged in the production, storage, transport, and distribution of chemicals and other substances used by the human and agricultural food and agriculture industry, including seeds, pesticides, herbicides, fertilizers, minerals, enrichments, equipment, and other agricultural production aids.
- Workers who support sawmills and the manufacture and distribution of fiber and forestry products, including, but not limited to timber, paper, and other wood and fiber products, as well as manufacture and distribution of products using agricultural commodities.
- Workers engaged in the manufacture and maintenance of equipment and other infrastructure necessary for agricultural production and distribution.
Government*: Other state and local government designated personnel required to provide essential services. This category includes but is not limited to:
- Local governments may designate any remaining personnel as may be required to provide essential services that are not otherwise included in Phase 1A or 1B.
- Certain designated personnel in the following state agencies:
  - All remaining DSS
  - All remaining DMH
  - All remaining OA
  - All DED
  - All remaining DHSS
  - All remaining MDA
  - All remaining MODOT
  - All remaining DCI
  - All remaining DESE
  - All remaining DHEWD
  - All remaining DOLIR
  - All remaining DNR
  - All remaining DOR
  - All remaining MDC
Higher Education: Faculty and staff at public, private, and/or nonprofit higher education institutions.

Disproportionately Affected Populations: Populations at increased risk of acquiring or transmitting COVID-19, with emphasis on racial/ethnic minorities not otherwise included in 1B.

Homeless: Populations at increased risk of acquiring or transmitting COVID-19, excluding those that were already included in 1B.

Medical History
Have you received any vaccination in the past 2 weeks? *

Yes No
When did you receive it?

Month Day Year
Date
Are you 65 or older? *

Yes No
Do you have any chronic condition that increases your risk for severe illness? *

Please show me examples of chronic conditions Yes No
Cancer

Chronic Kidney Disease

COPD (Chronic Obstructive Pulmonary Disease)

Intellectual and/or developmental disabilities such as Down syndrome

Heart Conditions such as heart failure, CAD (coronary artery disease) or cardiomyopathies

Immunocompromised state from solid organ transplant

Severe Obesity (BMI >40kg/m2)

Pregnancy

Sickle Cell Disease

Diabetes (Type I or Type II)
p1b2
p1a
p1b1
Current Phase
p1b3
p2
Client Phase
voice
email
text
either
how contact
Should be Empty:

Contact Information

Demographics

Occupation Description

Phase Definitions and Examples

Medical History