Vaccine Wait List- Harper County Health Dept.
Please fill out a separate form for each interested person.  This does not guarantee vaccine on a certain date, only indicates your interest.  We will contact you to set up an appointment when vaccine is available for you.  
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First and Last Name *
Date of Birth *
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DD
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Phone Number *
Email Address
Do you live in Harper County, Kansas? *
Where do you work? *
What is your role at work? *
Do you live or work in any of the following licensed congregate settings: *
Required
Do you have any of the following medical risks: cancer, chronic kidney disease, COPD, down syndrome, heart conditions, Type 2 diabetes mellitus, sickle cell disease, or are pregnant? *
Do you have any of the following medical risks: asthma, cerebrovascular disease, cystic fibrosis, immunocompromised state (from blood or bone marrow transplant, immune deficiencies, HIV, use or corticosteroids or other immune weakening medicines), neurologic conditions (such as dementia), liver disease, pulmonary fibrosis, thalassemia (a type of blood disorder), Type 1 diabetes mellitus, or obesity? *
If another Harper County healthcare facility has the COVID-19 vaccine available, may we have your permission to share your request and answers to this questionnaire? This would allow them to contact you and schedule an appointment for your vaccine, instead of the Harper County Health Department. *
Please leave any additional comments here:
Thank you!
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