Clay County COVID-19 Vaccine Sign-Up
The Clay County Health Department is committed to providing high-quality care to Clay County residents. With limited COVID-19 vaccines available, our focus is to request Clay County residents' names and contact information of individuals who would like to receive the COVID-19 vaccine. Vaccine distribution is based upon a pre-determined phasing system created using guidance from the Kansas Department of Health and Environment-
https://www.kansasvaccine.gov/DocumentCenter/View/120/Vaccine-Phase-Chart-PDF-
. Kansas will soon be entering Phase 2 when vaccines are available. To prepare, we encourage the following individuals to sign-up for the COVID-19 vaccine (per KDHE):
1. Health Care Workers
2. Firefighters/EMS/Police officers/Correction officers
3. Individuals 65 year or older
4. Grocery store workers and food service workers
5. K-12 and childcare workers
6. Food Processing
7. Transportation workers
8. Workers in retail, warehouses, sales, the supply of critical industrial/materials for COVID response, Agriculture, USPS, and Department of Motor Vehicles.
Once COVID vaccines are received, The Health Department will contact individuals eligible to vaccinate with an immunization location and time. We continue to ask you all to be patient as we continue to protect our community diligently. The COVID-19 vaccine is the best way we can all work together to end the pandemic!
For more information, please visit
https://www.kansasvaccine.gov/
.
* Required
Email address
*
Your email
First Name
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Your answer
Last Name
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Your answer
Birth Date
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MM
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DD
/
YYYY
Are you 65 years of age or older?
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Yes
No
Mobile phone (no dashes or slashes, please include area code)
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Your answer
Does this phone number receive text messages?
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Yes
No
Address
*
Your answer
Town
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Your answer
County
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Your answer
Zip
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Your answer
Do you work in healthcare?
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Yes
No
Are you employed?
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Yes
No
Place of Employment
Your answer
Does the person to be vaccinated have underlying health conditions (examples: Cancer, Heart Disease, Diabetes, Obesity, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Immunocompromised, Sickle Cell Disease, etc.)
*
Yes
No
If applicable, please list underlying health conditions. Mark N/A if you do not have any severe medical risks.
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Your answer
Have you ever received a dose of COVID-19 vaccine?
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Yes
No
If you have received a previous dose of COVID-19 vaccine, which product?
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Pfizer
Moderna
I have not received a previous dose of vaccine.
Required
Have you received another vaccine in the last 14 days?
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Yes
No
Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
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Yes
No
If you did test positive for COVID-19 or was told you had COVID 19 WHAT was the DATE?
MM
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DD
/
YYYY
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
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Yes
No
If you did receive passive antibody therapy when did you receive treatment?
MM
/
DD
/
YYYY
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?
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Yes
No
How would you prefer to receive your COVID-19 Vaccine?
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Office Appointment
Drive-Thru Clinic
No Preference
Are you Homebound or unable to leave your home?
Yes
No
Clear selection
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