COVID-19 Vaccine Interest Form

Please fill out this form to be included in an interest list for the COVID-19 vaccine. If you have multiple people in your family, please complete a separate form for each person. The City and County of Broomfield will contact you directly when the vaccine becomes available to you in your occupation/age group of the distribution plan. View the distribution plan here: https://drive.google.com/file/d/1bt8N-q3FvszKkhK4bo1sutfXsL7S-Oos/view?usp=sharing

Please understand the City and County of Broomfield is moving as quickly as possible, but vaccine distribution may take some time. This process is also dependent upon when additional doses of vaccine are allocated to Broomfield and which providers can administer the vaccine. You only need to complete the form once to be added to the notification list.

Sign up for the Broomfield Community Update (sent each Monday) at Broomfield.org/BintheLoop and to check Broomfield.org/COVIDVaccine often for updates on vaccine distribution within phases.

*If you do not have an email address, please put "phnotifications@broomfield.org" into the "Email Address" field, and include a valid phone number in to the "Phone Number" field. You will be contacted by phone.

Email address *

First Name *

Last Name *

Phone Number

Year of Birth *

Highest-risk health care & long-term care facility workers/individuals:

Health care workers who have direct contact with COVID-19 patients

Long term care facility staff

Long term care facility resident

Coloradans age 70+, moderate-risk health care workers, first responders, frontline essential workers, and continuity of state government:

Health care works with less direct contact with COVID-19 patients (home health, hospice, pharmacy, dental, etc.) and EMS.

Firefighters, police, COVID-19 response personnel, correctional workers, funeral services

Residents aged 70+ years old

Frontline essential workers in education, food and agriculture, manufacturing, U.S. postal service, public transit and specialized transportation staff, grocery, and public health, frontline essential human services workers, and direct care providers for Coloradans experiencing homelessness.

Essential officials from executive, legislative, and judicial branches of state government

Essential frontline journalists

Higher-risk Individuals and other Essential Workers

Residents ages 60-69 years old

People age 16-59 with obesity, diabetes, chronic lung disease, heart disease, chronic kidney disease, cancer

Other essential workers and continuity of local government

Adults who received a placebo in a COVID-19 vaccine trial

General Public

General Public - Anyone age 16 - 59

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