Last Name *

First Name *

Middle Initial

Date of Birth: (MM/DD/YYYY) *

Sex

Male
Female
Transgender
Other

Race

White
Black
Asian
Pacific Islander
American Indian/Alaskan Native
None Specified
Refused

Hispanic Ethnicity

Yes
No
Unknown
Refused

Address 1 *

Address 2

City *

State *

Zip Code *

County *

Cell/Primary Phone Number: (i.e., 555-555-5555) *

Home/Secondary Phone Number: (i.e., 555-555-5555)

Email Address

Would you like a reminder notification for the next appointment?

Yes
No

If yes, how?

Text Message
Email
Phone Call

Insurance Information (Please select one)

Private or employer insurance
Underinsured
Uninsured
Medicare
Medicaid

Phase Qualifications

Phase 1A - 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
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
N/A

Phase 1B - Tier 1 Worker Information: Protecting those who keep us safe and help during emergencies

First Responders
Non-Patient Facing Public Health Infrastructure
Emergency Management and Public Works
Emergency Services Sector
N/A

Phase 1B - Tier 2 High-Risk Individuals: Protecting those who are at increased risk for severe illness (Please select all options that apply)

Options:

Anyone aged 65 and older
Cancer
Chronic Kidney Disease
COPD (chronic obstructive pulmonary disease)
Intellectual and/or developmental disabilities such as Down syndrome
Heart Conditions (such as heart failure, coronary artery disease, or cardiomyopathies)
Immunocompromised state from solid organ transplant
Severe Obesity (BMI greater than 40)
Pregnancy
Sickle Cell Disease
Type 2 Diabetes Mellitus

Phase 1B - Tier 3 Critical Infrastructure: Protecting those who keep the essential functions of society running

Education (K-12)
Childcare
Communications Sector
Dams Sector
Energy Sector
Information Technology Sector
Nuclear Reactors, Materials, and Waste Sector
Transportation Systems Sector
Water and Wastewater Systems Sector
Government: Certain elected/appointed officials or other personnel designated by the executive, legislative, and judicial branches of state government
Food/Agriculture Sector – initial: Employees of certain food production and processing facilities, and related operations, prioritizing mass food production, distribution, transportation, wholesale, veterinary serves, and retail sales.
N/A

Phase 2, Equity & Economic Recovery: Protecting those who have been disproportionately affected and accelerating economic recovery

Chemical Sector
Commercial Facilities Sector
Critical Manufacturing Sector
Defense Industrial Base Sector
Financial Services Sector
Higher Education
Disproportionately Affected
Homeless
Government: Other state and local government designated personnel required to provide essential services
N/A

Phase 3, Remaining Unvaccinated Populations: Protecting everyone else who has not been vaccinated, but wants to do so

Resident who doesn’t fall into the above phases/tiers
N/A