COVID-19 Vaccination Interest Form - Clear Creek County, CO
Our goal is to provide the community with COVID-19 vaccinations as quickly and safely as possible, following the State's phased approach. Clear Creek County is collecting information in order to plan for, and continue vaccinating, Phase 1A and Phase 1B, as well as prepare for subsequent phases. As a reminder, the phases are as follows:

Phase 1A: Highest Risk Healthcare Workers and Individuals
• Inpatient Healthcare Workers, ICU, ED Staff, Assisted Living Facility Residents and Staff
• Long Term Care staff and residents
• EMS, staff working with at-risk populations
• COVID-19 Testing Staff
• Outpatient medical providers (physician/nurse/ancillary staff) who have direct contact with positive COVID-19 patients.

Phase 1B.1: Coloradans age 70+, moderate-risk healthcare workers, 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.
• People age 70 and older.

Phase 1B.2: Coloradans ages 65 - 69, pre K-12 educators and child care workers in licensed child care programs, and continuity of state government
• 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.
• Members of the Executive and Judicial branches of state government.
• People age 65 - 69.

Phase 1B.3: Frontline essential workers and people age 16 - 64 with two or more high risk conditions
• Frontline essential workers in food and agriculture, manufacturing, U.S. Postal Service, public transit and specialized transportation staff, grocery, and public health, frontline essential human service workers, faith leaders, and direct care providers for Coloradans experiencing homelessness.
• Essential frontline journalists.
• People 16 - 64 with 2 or more high risk conditions as listed: cancer, chronic kidney disease, COPD, diabetes mellitus, down syndrome, specific heart conditions, obesity, pregnancy, sickle cell disease, solid organ transplant, and people with disabilities that prevent them from wearing masks.

Phase 2: People age 60 - 64, people with high risk conditions, and the continuation of operations for state government and continuity of local government
• People age 60 - 64
• People age 16 - 59 with 1 high risk condition as listed: cancer, chronic kidney disease, COPD, diabetes mellitus, down syndrome, specific heart conditions, obesity, pregnancy, sickle cell disease, solid organ transplant, and people with disabilities that prevent them from wearing masks.
• Continuity of local government defined as executives of those branches of government and a limited amount of essential support staff needed to provide for continuity of government.
• Continuation of local operations for state government is defined as those individuals defined by continuity of operations plans that each agency holds to continue to provide services.

Phase 3: The general public
• Anyone age 16 - 59

The county receives a limited amount of vaccines periodically from the state. We currently receive the Moderna vaccine, which requires 2 doses, 28 days apart.

If you are a business looking to get your staff vaccinated, please fill out the Business Vaccine Form: https://forms.gle/TTTejpgySKDi1vBw6.

As a friendly reminder, this form will not schedule you for an appointment to get the vaccine. This form is to collect information of interested persons wanting to get the vaccine when it becomes available to them, and to assist Clear Creek County with their planning. As vaccines become available to your phase, we will make you aware as to how to schedule yourself for a vaccine.
Email address *
First and Last Name (one person per submission): *
Phone Number: *
Description of Phases:
Phase 1A: Highest Risk Healthcare Workers and Individuals
• Inpatient Healthcare Workers, ICU, ED Staff, Assisted Living Facility Residents and Staff
• Long Term Care staff and residents
• EMS, staff working with at-risk populations
• COVID-19 Testing Staff
• Outpatient medical providers (physician/nurse/ancillary staff) who have direct contact with positive COVID-19 patients.

Phase 1B.1: Coloradans age 70+, moderate-risk healthcare workers, 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.
• People age 70 and older.

Phase 1B.2: Coloradans ages 65 - 69, pre K-12 educators and child care workers in licensed child care programs, and continuity of state government
• 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.
• Members of the Executive and Judicial branches of state government.
• People age 65 - 69.

Phase 1B.3: Frontline essential workers and people age 16 - 64 with two or more high risk conditions
• Frontline essential workers in food and agriculture, manufacturing, U.S. Postal Service, public transit and specialized transportation staff, grocery, and public health, frontline essential human service workers, faith leaders, and direct care providers for Coloradans experiencing homelessness.
• Essential frontline journalists.
• People 16 - 64 with 2 or more high risk conditions as listed: cancer, chronic kidney disease, COPD, diabetes mellitus, down syndrome, specific heart conditions, obesity, pregnancy, sickle cell disease, solid organ transplant, and people with disabilities that prevent them from wearing masks.

Phase 2: People age 60 - 64, people with high risk conditions, and the continuation of operations for state government and continuity of local government
• People age 60 - 64
• People age 16 - 59 with 1 high risk condition as listed: cancer, chronic kidney disease, COPD, diabetes mellitus, down syndrome, specific heart conditions, obesity, pregnancy, sickle cell disease, solid organ transplant, and people with disabilities that prevent them from wearing masks.
• Continuity of local government defined as executives of those branches of government and a limited amount of essential support staff needed to provide for continuity of government.
• Continuation of local operations for state government is defined as those individuals defined by continuity of operations plans that each agency holds to continue to provide services.

Phase 3: The general public
• Anyone age 16 - 59
Based on the above information, I qualify as: *
If submitting as Phase 1A or 1B.1, healthcare workers or first responders, I confirm that: *
If submitting as Phase 1B.1, Coloradans aged 70+, I confirm that: *
If submitting as Phase 1B.2, I confirm that: *
If submitting as Phase 1B.3, I confirm that: *
If submitted as Phase 2, I confirm that: *
If submitting as Phase 3, I confirm that: *
Are there any barriers that would prevent you from transporting yourself to a vaccination site? *
I confirm that all the above information is correct. *
Required
A copy of your responses will be emailed to the address you provided.
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