Vaccination Sign Up Form (Phase 1B)
Must be a Lebanon County resident or employed in the county and one of the following:
• First responders (Fire and Law Enforcement)
• Correctional officers and other workers serving people in congregate care settings not included in Phase 1A
• Food and agricultural workers
• U.S. Postal Service workers
• Manufacturing workers
• Grocery store workers
• Education workers
• Clergy and other essential support for houses of worship
• Public transit workers
• Individuals caring for children or adults in early childhood and adult day programs
*These categories are general groups. For a more granular list of eligible positions please consult the DOH vaccine plan found here:
https://www.health.pa.gov/topics/Documents/Programs/Immunizations/PA%20Interim%20Vaccine%20Plan%20V.4.pdf
*Additional vaccine guidance can be found at the Department of Health's website here:
https://www.health.pa.gov/topics/disease/coronavirus/Pages/Vaccine.aspx
* Required
Email address
*
Your email
Which workforce category best fits your occupation?
*
Choose
Law Enforcement
Fire Rescue Personel
Correctional Officer
Food and Agriculture
US Postal Service
Manufacturing
Education
Clergy / Houses of Worship
Public Transit
Child Care Services
All Other
If "All Other" selected above, please describe your service industry
Your answer
Last Name
*
Your answer
First Name
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Cell Phone Number
*
Your answer
Phone Number Extension
Your answer
Name of Employer, Company, or Agency
*
Your answer
Employment Verification Contact Name (HR, Supervisor, Etc.) - First and Last
*
Your answer
Employment Verification Contact Title or Position
*
Your answer
Employment Verification Contact Number (HR, Supervisor, Etc.)
*
Your answer
Employment Verification Contact Number (HR, Supervisor, Etc.) Extension
Your answer
Have you tested positive for Covid-19 within the past 90 days?
*
Yes
No
Scheduling and Appointments
Make sure that all your information is correct before submitting this form. After eligibility is validated we will be contacting you with specific scheduling availability and pertinent paperwork required in order to complete your vaccination.
A copy of your responses will be emailed to the address you provided.
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