Pacific County Health & Human Services- COVID Vaccine Information Sign Up
Please complete this form if you are interested in receiving direct communications (via email) from the Pacific County Health Dept. with updates on COVID 19 vaccine planning including information about priority groups to receive the vaccine and information on when and how to schedule an appointment (once eligible). Please note- currently vaccines are limited to only those in the 1a priority group (healthcare workers, long term care residents or staff, and emergency medical responders). As new priority groups open up, we will send you updates that include newly eligible priority populations. Please call us at M-F 8:00-4:00 at 360-875-9407 or 360-642-9407 with any questions.
Name
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Email
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Mailing address
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Phone number
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Age
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Do you have any underlying medical conditions?
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No
Prefer not to answer
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Do you work or volunteer in any of the following fields?
Healthcare (position requires direct patient contact)
Healthcare (position does not required direct patient contact)
Long Term Care or other residential care where most individuals are age 65+
Resident of a long term care facility
Emergency Medical Services (EMS)
Law enforcement
Other residential facility (i.e. inpatient substance use treatment)
Education/schools (staff)
Cannery or other food/agriculture processing
Other congregate work setting (please list in next section)
Other essential worker (please list in next section)
Other (please list in next section)
If not listed above, please list your occupation here.
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Once eligible, do you plan to take the vaccine?
Yes
No
Undecided
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Any other comments?
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