Jackson County Health Department COVID-19 Vaccine Survey

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Are you interested in receiving the COVID-19 Vaccine?

Based on availability, and guidance from the Missouri Department of Health and Human Services (MO DHSS) and the Center for Disease Control (CDC), the Jackson County Health Department will be providing the COVID-19 vaccine based on a pre-determined tier system. Individuals will be identified to receive the vaccine based on risk status and occupation.

Once the vaccine is made available for your tier, the Jackson County Health Department will use your information from the survey below to contact you with further instructions on how to schedule an appointment to receive your vaccination.

Per the guidance provided by the CDC, COVID-19 vaccinations will not be provided to those under the age 16.
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Name* This field is required.
First Name
Last Name
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Date of Birth
Date
Month
Day
Year
4
Current Age* This field is required.
5
Ethnicity
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Prefer not to answer
Type option 4
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Are you of Hispanic, Latino, or of Spanish origin? (ethnicity)
Yes
No
Prefer not to answer
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How would you describe yourself? (race)
White/Caucasian
Asian
Black/ African American
Native Hawaiian/ Pacific Islander
American Indian/Alaska Native
Prefer not to answer
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Zip Code* This field is required.
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Phone Number* This field is required.You MUST provide a phone number in order to be alerted to vaccine availability.
Please enter a valid phone number.
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Email* This field is required.You MUST provide an email to be alerted to vaccine availability via email. If you do not have one, click next below
example@example.com
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Work Status* This field is required.
Full Time
Part Time
Unemployed
Retired
Student
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Are you employed by any of the following types of patient-facing organizations: (hospital, physicians office, behavioral health, dialysis center, outpatient healthcare, dental office, other healthcare, school district-nurse, or EMS)* This field is required.
Yes
No
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Please choose the type of organization you are employed by:
Hospital
Physicians Office
Behavioral Health
Dialysis Center
Outpatient Healthcare
Other Healthcare
School District-Nurse
EMS
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Are you employed by any of the following types of organization: (non-patient facing public health infrastructure, first responders, emergency management and public works, or emergency services sector?* This field is required.
Yes
No
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Please choose the type of organization you are employed by:
crematory operators
embalmers
emergency management (federal, state, or local)
emergency services sector
first responders (federal, state, or local)
morticians
public health (federal, state, or local)
public works
social service agencies
undertakers
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Please select the following sector you work in. (if any)
Education
Chemical Sector
Childcare
Commercial Facilities Sector
Communications Sector
Critical Manufacturing Sector
Dams Sector
Defense Industrial Base Sector
Financial Services Sector
Energy Sector
Food/Agriculture (food production, processing, distribution, transportation, retail, grocery, or convenience, animal care veterinarians and support)
Food/Agriculture (restaurant service)
Government (elected officials in any branch at any level)
Government (all other employees)
Higher Education
Information Technology Sector (public, private or nonprofit providing IT services)
Transportation Systems (aviation, highway, motor carriers, maritime, mass transit, passenger rail, pipeline systems, freight rail, postal shipping)
Water and Wastewater Systems (drinking or wastewater services)
None of the Above
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Please list the type of agency you are employed by (i.e. retail, pharmaceutical, food service, transportation, etc.) :
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Please provide the name of your employer:* This field is required.
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What is your job title and/or role at your organization?* This field is required.
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Do you have any pre-existing medical conditions or do you have any conditions that put you at increased risk of severe illness? (i.e. immunocompromised, diabetes, chronic lung conditions, cardiovascular disease, morbid obesity, etc.)* This field is required.
YESNO
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Would you like to submit information for any additional members of your household, over the age of 16?
YESNO
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Name* This field is required.
First Name
Last Name
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Race
White/ Caucasian
Black/ African American
Asian
Native Hawaiian/ Pacific Islander
American Indian/ Alaskan Native
Prefer not to answer
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Phone Number* This field is required.
Please enter a valid phone number.
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EmailYou MUST provide an email to be alerted to vaccine availability via email. If you do not have one, click next below
example@example.com
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Would you like to submit information for any additional members of your household, over the age of 16?
YESNO
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Name
First Name
Last Name
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Race
White/ Caucasian
Black/African American
Asian
Native Hawaiian/ Pacific Islander
American Indian/ Alaskan Native
Prefer not answer
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Phone Number
Please enter a valid phone number.
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EmailYou MUST provide an email to be alerted to vaccine availability via email. If you do not have one, click next below
example@example.com
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I consent to receive email notifications regarding COVID-19 vaccination availability and clinic opportunities based on my assigned tier group.
YESNO
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I consent to receive text message notifications regarding COVID-19 vaccination availability and clinic opportunities based on my assigned tier group. Message and data rates may apply. * This field is required.
YESNO
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