Ottawa County, Ohio COVID-19 Vaccine Pre-Registration (1B Individuals)
Please complete the form below to pre-register for Phase 1B. Once Ottawa County begins this vaccination phase we will notify you via phone number and/or email address you provide. Please double check your contact information as it is vitally important to ensure we can reach you when ready.

Phase 1B
- people age 65 and older
- people living with severe congenital, developmental, or early-onset medical conditions
- adults who work in schools (K-12)
First name of individual to be vaccinated *
First Name
Last Name of individual to be vaccinated *
Last Name
Date of Birth *
Date
MM
/
DD
/
YYYY
Phone number *
Please DOUBLE-CHECK your phone number for accuracy. Phone numbers should be entered in the XXX-XXX-XXXX format.
Do you want Covid-19 text updates through this number. (Cell Phones Only) *
Street Address (including apartment number if relevant) *
City of Residence *
State of Residence *
Postal/Zip Code of Residence *
County of Residence *
Email address *
If you do not have an email address, please enter N/A
Select your employment sector *
What is the name of your primary place of employment? (This is where you work the most hours) *
If you are retired or currently not working, please enter either RETIRED or UNEMPLOYED.
What is your position/title at your primary place of employment? *
If you are retired or currently not working, please enter either RETIRED or UNEMPLOYED.
Where is your primary place of employment located? *
Which of the following describes you? (Select all that apply.) *
Required
I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. *
If you are completing this survey for someone else, please write your name and relationship to individual.
First and Last Name/Relationship
Submit
Never submit passwords through Google Forms.
This form was created inside of Ottawa County, Ohio. Report Abuse
Google Forms