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Pacific County School Employees
Please complete this form only if you:
1) Are a current employee of a school district in Pacific County, or if you are an employee of ESD 112 or ESD 113 and primarily work in a Pacific County School; AND
2) You have not yet received the COVID vaccine and you want a provider to reach out to you to schedule an appointment once you are eligible
As school employees, you are considered essential workers and will be eligible for the vaccine once the state opens up Phase 1b tier 2 (essential workers over 50), or 1b tier 4 (essential workers under 50). Once that happens, and when we receive vaccine, a provider in Pacific County will reach out to set up a vaccine appt for you.
Please complete one form per person.
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* Indicates required question
Last Name
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Your answer
First Name
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Your answer
Employer
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Choose
Ocean Beach School District
Naselle School District
South Bend School District
Raymond School District
Willapa Valley School District
North River School District
ESD 113 (indicate which school building you work at in the next section)
ESD 112 (indicate which school building you work at in the next section)
Position
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Your answer
Date of birth
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MM
/
DD
/
YYYY
Age
*
Your answer
Address
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Your answer
City
*
Your answer
Zip code
*
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email address
*
Your answer
Emergency Contact Person
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Your answer
Emergency Contact Person Phone Number
*
Your answer
Ethnicity
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Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Race
*
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Prefer not to answer
Do you have a known history of a severe allergic reaction (e.g. anaphylaxis) to this vaccine or any components of the vaccine such as lipids, potassium chloride, monobasic potassium phosphate, sodium chloride, dibasic sodium phosphate dihydrate, and sucrose?
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Yes
No
In the past two weeks, have you tested positive for COVID-19?
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Yes
No
In the past 2 weeks, have you had exposure to a person who tested positive for COVID-19 at a distance of 6 feet or less for more than 15 minutes without personal protective equipment, such as masks?
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Yes
No
Have you had new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste/smell, sore throat, nausea, vomiting or diarrhea?
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Yes
No
In the past 90 days have you received passive antibody therapy as part of COVID-19 treatment?
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Yes
No
Are you pregnant or breastfeeding or do you plan to become pregnant?
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Yes
No
Are you immune compromised or on a medicine that affects your immune system?
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Yes
No
Do you have a bleeding disorder or are you on a blood thinner?
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Yes
No
Do you have a history of severe allergic reaction (anaphylaxis) to another vaccine or injectable medication?
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Yes
No
Have you received any other vaccinations in the past two weeks?
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Yes
No
Do you have insurance?
Yes
No
Clear selection
If yes, which company is your insurance through?
Your answer
Insurance company address
Your answer
Insurance Group Number
Your answer
Insurance ID Number
Your answer
Name of primary subscriber
Your answer
Submit
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