COVID-19 Vaccine Request
Please answer the following questions if you would like to receive the Moderna Covid-19 vaccine. We will call you when we have a dose available to you.
Which vaccine are you requesting?
Moderna (2 doses separated by 28 days)
Janssen (1 dose only)
Which of the following apply to you
Fire, police, 911, correctional staff, search and rescue or other in-person ER response personnel
Funeral Service practitioners and in-person employees necessary for funerals
Over the age of 50
Healthcare providers, behavioral health provider and social workers
K-12 education (teachers and support staff)
Child Care service providers
Those with the following conditions: cancer, chronic kidney disease,
chronic obstructive pulmonary disease, solid organ transplant, sickle cell disease, down syndrome
pregnancy (Pregnant women should discuss vaccination with their provider in advance).
People on the Wyoming Medicaid Community Choices Waiver and Developmental Disabilities waivers
Those with the following conditions: diabetes, heart conditions, obesity (BMI over 30),
immunocompromised state, severe neurologic conditions (stroke and dementia)
Caregivers who are caring for a person who is at high risk of COVID-19 illness above
Workforce service center employees, port of entry employees, veterinarians,
court system employees, non-law enforcement security officers
Attorneys, judges, and court personnel necessary for in person criminal hearings or trails.
Custodial staff responsible for cleaning areas known to have been contaminated by people positive for COVID-19
Legislators and Legislative Service Office staff and volunteers required for in-person sessions of the Wyoming State Legislature.
Essential Critical Infrastructure Workforce who are unable to physically distance or telework.
Moderate to severe asthma, high blood pressure, liver disease, overweight (BMI 25-30), Thalassemia
None of the above but would like to receive a dose when it's available to me.
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This form was created inside of State of Wyoming.