Full Name (First Name & Last Name)*

Email Address*

Age*

Date of Birth

Home Address

Phone Number (Cell Phone Preferred)*

Acknowledgement -- Because the supply of COVID-19 vaccine in the United States is expected to be limited at first, the CDC is providing recommendations to federal, state, and local governments about who should be vaccinated first. CDC’s recommendations are based on recommendations from the Advisory Committee on Immunization Practices (ACIP), an independent panel of medical and public health experts. The recommendations were made with these goals in mind: *Decrease death and serious disease as much as possible. *Preserve functioning of society. *Reduce the extra burden COVID-19 is having on people already facing disparities.*

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Vaccination Phase -- Please choose the Vaccination Phase that best describes your situation or condition. **This is an interim vaccine plan. Many of the components of the COVID-19 vaccine plan remain fluid and may be modified and adapted based on decisions made at the federal, state and county levels.****

Phase 1-A: Generally healthcare workers who have regular potential exposure to COVID-19 patients and residents and staff of long-term care facilities
Phase 1-B: Persons 70 years of age and older, funeral service practitioners, and in-person employees within congregate care settings
Phase 1-B: People 65-69 years old, behavioral health providers and social workers unable to physically distance, K-12 education (teachers and other school district staff), childcare and adult daycare providers.
Phase 1-B: Public transit employees, those with the following conditions: cancer, chronic kidney disease, COPD, solid organ transplant, sickle cell disease, down syndrome and pregnancy (Pregnant women should discuss vaccination with their provider in advance)
Phase 1-B: Grocery store employees, people on Wyoming Medicaid Community Choices Waiver and Developmental Disability waivers
Phase 1-B: US Postal Service and delivery service companies (such as FedEx and UPS) likely to have public exposure, those with the following conditions: diabetes, heart conditions, obesity (BMI over 30), immunocompromised state, severe neurologic conditions (stroke and dementia)
Phase 1-B: Workforce service center employees; port of entry employees; parole and probation officers; veterinarians; court system employees; and non-law enforcement security officers that must have in-person close interactions, unable to physically distance and unable to provide services virtually; attorneys, judges, and court personnel necessary for in person criminal hearings or trials; and custodial staff responsible for cleaning areas known to have been contaminated by people positive for COVID-19. Caregivers who are caring for a person who is at high risk of COVID-19 Illness and cannot receive the vaccine
Phase 1-C: All other essential workers: workers in transportation and logistics, water and wastewater, food service, shelter and housing (e.g., construction), finance (e.g., bank tellers), information technology and communications, energy, legal, media, and public safety (e.g., engineers), and public health workers
Phase 2: All individuals not previously covered who are 18 and older and do not have a contraindication to the vaccine

Please provide additional information or context that you feel might be relevant

Please visit the Wyoming Department of Health for the latest information on vaccine phases and distribution https://health.wyo.gov/publichealth/immunization/wyoming-covid-19-vaccine-information/

Acknowledgement: please note that your submission of a response to this survey does not guarantee that you will receive a vaccine. We are following the strict CDC and WY DOH guidelines on prioritization of vaccine. We kindly ask that you do not contact the pharmacy for an update on when you will be getting your vaccine. We assure you that you will be contacted AS SOON AS we have vaccine available and you are eligible.*

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COVID Vaccination Request Form