COVID-19 Tier 1A Vaccine Survey
Eligible Persons for Tier 1A
Tier 1A is defined as:

Healthcare workers with patient contact, or with contact with infected materials
Long-term care residents
Long-term care staff

This survey is intended to collect information on Clinton County residents who are Tier 1A workers who have not been vaccinated by their employer.

We must verify you meet eligibility requirements under this category before being vaccinated
What is your Name? *
Are you a Clinton County Resident? *
What is your Home Address? *
What is your phone number *
What is your email address? *
Who is Your Employer? (Answer N/A if No Employer)
Have COVID-19 Vaccinations been made available through your employer
Clear selection
If Unemployed, what is your occupation?
Never submit passwords through Google Forms.
This form was created inside of Clinton County Health Department. Report Abuse