Silver Thread Public Health District Covid-19 Vaccination Sign-Up Form

Thank you for your interest in receiving the COVID-19 Vaccine! We are collecting this information so that we can efficiently and equitably administer the limited vaccine doses that we are receiving. Details on who is eligible during each phase of the vaccine roll out can be found here: https://covid19.colorado.gov/vaccine.

Signing up here will enter your information into our system and you will receive a phone call as soon as we have an appointment available for your group. Please press submit at the end of the survey and your information will be recorded in our system.

While filling out this form will inform us of the number of people interested in receiving a vaccine in each phase, it does not guarantee a vaccine in any timeframe. When your time comes in the phases, you will be notified via phone or email to schedule an appointment for both doses of the vaccine 28 days apart. Please only register using this form once per person.

We currently have the Moderna Vaccine which is approved for adults over 18 years old. Each person 18 years and older in your household who is interested in receiving the vaccine should register as a separate entry. We encourage families to register their children under 18 as well, should a time come for a vaccine for younger age groups. However, there is no available information on when or if that may occur.

Thank you for working with us to help keep our community safe and healthy,
Your Silver Thread Public Health Team

First and Last Name *

Date of birth (MM/DD/YYYY) *

YYYY

Age *

Gender *

Male

Female

Other:

Phone Number (xxx-xxx-xxxx) *

E-mail (If you do not have an E-mail please put N/A) *

Mailing Address *

Street Address *

City *

County of Residence *

Mineral County

Hinsdale County

Other:

State *

Zip Code *

Race/Ethnicity (check all that apply)

Asian

Black, African American

Native Hawaiian/Pacific Islander

American Indian/Alaskan Native

Hispanic/Latino

White

Other:

To which vaccine group do you belong? Please select ONE. If you belong to multiple groups, please select the FIRST group in the list below that you belong to. *

High-risk health care workers and individuals with direct contact to COVID-19 patients

Long-term care facility staff and residents

Moderate-risk health care workers and first responders: Health care workers with less direct contact with COVID-19 patients (e.g. home health, hospice, pharmacy, dental, etc.) and EMS.

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

PK-12 Educators and childcare workers in licensed child care programs: Child care workers in licensed child care programs, teachers (full-time and substitutes), bus, food, counselors, administrative, safety, and other support services offered inside the school.

State government worker in executive and judicial branches.

Frontline essential worker in Grocery or Agriculture: The intent of this classification is to prioritize current workers who cannot maintain physical distance from others at their place of employment, who work in close contact with many people, especially indoors, and in places with poor ventilation including meatpacking workers; grocery store workers; and agricultural processing workers.

People age 16-59 with two or more of these high-risk conditions: Cancer (defined as patients who are currently receiving treatment or have received treatment within the last month for cancer), chronic kidney disease, COPD, diabetes mellitus (types 1 and 2), Down syndrome, specific heart conditions (heart failure, cardiomyopathies or coronary heart disease, and severe valvular/congenital heart disease), obesity (BMI of 30 or more), pregnancy, sickle cell disease, solid organ transplant, individuals with disabilities who require direct care in their home, and people with disabilities that prevent them from wearing masks.

Higher Education frontline essential worker: The intent of this classification is to prioritize current educators who work in close contact with many people especially indoors, including all student-facing staff in community colleges and colleges. Student-facing staff includes instructors, professors, vocational educators and staff providing safety and other support services offered inside the school.

Food/restaurant frontline essential worker: The intent of this classification is to prioritize current workers who cannot maintain physical distance from others at their place of employment, who work in close contact with many people, especially indoors, including but not limited to restaurant cooks, dishwashers, servers, and other workers in restaurant settings; and food pantry/assistance workers.

Manufacturing frontline essential worker: The intent of this classification is to prioritize workers in manufacturing settings who cannot maintain physical distance from others at their place of employment and workers who work in close contact with many people, especially indoors and in places with poor ventilation.

US Postal Service frontline essential worker: The intent of this classification is to prioritize current workers who work for the US postal service in positions where they cannot maintain physical distance at work and work in close contact with many people, especially indoors. This includes post office clerks and mail sorters.

Public transit and specialized transportation frontline essential worker:: The intent of this classification is to prioritize current workers in public transit and who have specialized transportation staff who cannot maintain physical distance from others at their place of employment, workers who work in close contact with many people especially indoors including but not limited to bus drivers, specialized transportation staff who work in our tunnels, specialized transportation staff such as air traffic controllers, train conductors, pilots, and airline stewards.

Public health frontline essential workers: The intent of this classification is to prioritize current workers in governmental public health agencies with public facing duties and heightened risk of exposure. This includes public health and environment staff, including inspectors, engaged in direct public health service delivery.

Manufacturing Front Line Worker (Unable to work from home with high levels of interaction with the public or others in the workplace)

Public Utilities Front Line Worker (Unable to work from home with high levels of interaction with public or others in the workplace)

U.S. Postal Service Front Line Worker (Unable to work from home with high levels of interaction with the public or others in the workplace)

Human service frontline essential workers: The intent of this classification is to prioritize current workers who cannot maintain physical distance at their place of employment in the course of their work, such as those who work in close contact with other people, especially indoors. This includes but is not limited to social workers, community health workers, those who work in client homes, in community locations, and at human services work locations, and others who provide direct or in-person services to elderly and disabled populations, at domestic violence advocacy organizations, or in-person resource providers.

Faith leaders: The intent of this classification is to prioritize those who in the course of leading faith services cannot easily maintain physical distance and must come into close contact with other people indoors. This includes current faith leaders who must enter hospitals or other care facilities to perform last rites, who officiate life rites such as weddings and baptisms, and who lead worship services.

Direct care providers for Coloradans experiencing homelessness: The intent of this classification is to prioritize workers who work in close contact with many other people, especially indoors, including but not limited to those who work and provide direct services in shelters for people experiencing homelessness.

Frontline essential journalists: The intent of this classification is to prioritize journalists who in the course of their work cannot easily maintain physical distance and come into contact with the public in the course of their work while conducting interviews or covering live events, especially indoors.

Continuity of local government: The intent of this classification is to ensure the continuity of county, municipal and other local governments. It includes select executives of those governments and a limited amount of essential support staff needed to provide for continuity of government, including members of the judicial branch who regularly come into contact with the public (e.g. state and county court trial judges, court administrators, public defenders and probation staff.)

Continuation of operations for state government: The intent of this classification is to ensure the continuity of essential state government services. It includes select staff needed to deliver essential services to the people of Colorado , as identified in the agencies’ continuity of operations plans.

People age 16 to 49 with one of the following higher risk conditions: The intent of this classification is to vaccinate Coloradans who have risk of severe outcomes from COVID-19. It includes Coloradans with one condition listed in 1B.3 or asthma (moderate-to-severe), Cerebrovascular disease (affects blood vessels and blood supply to the brain), Cystic fibrosis, Hypertension or high blood pressure, Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines, Neurologic conditions, such as dementia, Liver disease, Pulmonary fibrosis (having damaged or scarred lung tissues), Thalassemia (a type of blood disorder).

Under 18 years old

Clinical trail participant who received a placebo

General Public

Other:

Have you received your first dose of the Covid-19 Vaccine? *

Yes

Is there any additional information you would like us to know about you?

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