PCGHD Phase 1A COVID-19 Vaccine Registration
Please register using this survey so we can develop a schedule to make vaccine distribution quick and efficient. Once vaccine is available and ready to administer, you will receive an email from us with the time/date/location regarding your COVID-19 Vaccination.
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Full Name
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Your answer
Home Address
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Your answer
Email Address
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Your answer
Phone Number
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Your answer
Date of Birth
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MM
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DD
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YYYY
Name of Employer
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Your answer
Employer Address
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Your answer
Job Title
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Work phone number
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Your answer
Please select the Phase 1A population you fall under:
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Home Health Worker
Hospice
Dialysis Center
Nursing Home
Assisted Living Facility
Veteran's Home
Group Home
Developmental Disabilities Group
Dental/Vision Provider
Other Healthcare Worker
Required
Please list any known allergies.
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Your answer
I have read the emergency use authorization: Moderna:
https://drive.google.com/file/d/1ZMcGW0oU2X3kYLAmy62JZGpvSa0lZ5jB/view
Pfizer:
https://drive.google.com/file/d/1M0BUq34Pl6GnV2i8FYNbEI9UPJE4GO3g/view
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