COVID 19 Vaccine Waiting List

To ensure that all individuals wanting a COVID-19 vaccination receive one, Dunklin County Health Department is creating a list of individuals that will receive notification of vaccine availability, clinic locations, dates and times as we move through the different Phases. Please complete the following survey to be added to the list. We will follow state guidance as we move through the different phases. It's very important that you provide an email address to us as that will be the primary means of communication once we start moving through the subsequent Phases. Filling out the survey should take less than 5 minutes of your time. We appreciate your continued efforts to slow the spread of Coronavirus in our community. PLEASE ONLY REGISTER ONCE. IF YOU ARE ALREADY ON A WAITING LIST YOU DO NOT NEED TO REGISTER AGAIN!

Email address *

First Name *

Last Name *

Gender *

Female

Male

Prefer Not to Say

Other:

Required

Date of Birth *

YYYY

How old are you? *

The US Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) to permit the emergency use of the Coronavirus vaccines in individuals 18 years of age and older.

Street Address *

City *

State *

Postal Zip Code *

County of Residence *

Dunklin

New Madrid

Pemiscott

Stoddard

Other:

Phone example: (573) 000-0000 *

Employer *

Please Select All That Apply *

Health Care Worker

Long Term Care Facility Resident / Staff

High Risk Individual with Chronic Health Condition

First Responder

Essential Worker

Population at Increased Risk (such as prisoners, homeless, etc.)

Missouri Resident

Other:

Required

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