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COVID-19 Vaccine Information Form for Health Care Workers in Phase 1A

2. This form is for health care workers who are in Phase 1A only. Please complete the form below if you fall within Phase 1A and wish to receive a COVID-19 vaccine.
   This form is to be completed by those who fall into Phase 1A of the COVID-19 vaccination prioritization guidance. This includes health care workers part of the health care infrastructure. Please do NOT complete this form unless you are a health care worker. Please see this webpage for further definition of those who fit into Phase 1A: http://bchdmi.org/1745/COVID-19-Vaccine-Information After completing this form, you will receive additional information regarding how to make an appointment to receive your COVID-19 vaccine.

   This form is to be completed by those who fall into Phase 1A of the COVID-19 vaccination prioritization guidance. This includes health care workers part of the health care infrastructure. Please do NOT complete this form unless you are a health care worker. Please see this webpage for further definition of those who fit into Phase 1A: http://bchdmi.org/1745/COVID-19-Vaccine-Information After completing this form, you will receive additional information regarding how to make an appointment to receive your COVID-19 vaccine.

4. Your Name (first and last)*

5. Email Address*

7. Phone Number*

9. Your Job Title/Profession*

   This survey is for health care workers or those part of the health care infrastructure only. Please describe your role within the health care system that fits within Phase 1A of the vaccination prioritization plan.

11. Your Employer*

13. Employer Phone Number*

15. Employer Email Address*

17. Employer Adresss*

19. City*

20. State*

21. Zip Code*

23. Additional Information

    If responding on behalf of an organization or business, please indicate how many people are in your facility that would want to receive a vaccine.

Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field