Vaccine Waitlist Sign Up Form- South Central Public Health District

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Thank you for your interest in receiving the COVID-19 vaccine. We only schedule clinics one week in advance to make sure there is enough vaccine. Because of the extremely high volume of calls we are currently receiving, we are asking everyone interested in receiving the vaccine to sign up on this waiting list. The waiting list is the only way to get an appointment. We are not taking appointments over the phone.

As soon as there is a vaccine appointment available, we will go down the waiting list and call people to schedule an appointment. Please keep the phone you list on this form handy so we can sign you up for a vaccine as soon as possible. We will call you twice before moving on to the next person on the waiting list.

Please understand, because Idaho has a very limited supply of vaccine, it is expected to take 10 or more weeks to provide vaccine to everyone over the age of 65.

If you would prefer to receive vaccine through another local provider, you may find a list of options here: https://www.phd5.idaho.gov/Covid-vaccine-priority/

Please do not book more than one appointment and please honor any appointments you schedule. The vaccine has to be prepared in advance. Failing to show for your appointment places that dose at risk and takes away another person's chance to be vaccinated.

Idaho has a Vaccine Advisory Committee that has established priority groups who will receive vaccine first. You may find that list here: https://coronavirus.idaho.gov/idaho-covid-19-vaccine-advisory-committee/

Are you home-bound?

Yes

Clear selection

If you are home-bound, Do you need help getting to a vaccine center?

No, I have a family member/friend who can help me.

No, I have an agency/facility that can help me.

Yes, I need assistance getting to a vaccine center.

Yes, I cannot leave my house and need someone to come to me.

I am not home-bound.

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First Name *

Last Name *

What is a phone number we can use to contact you? *

Can we text you with this number? *

Yes

Can we call you with this number? *

Yes

Email Address *

Street Address *

City *

Zip Code *

County *

Blaine

Camas

Cassia

Gooding

Jerome

Lincoln

Minidoka

Twin Falls

Date of Birth: Please use the format MM/DD/YYYY ( Example - 01/01/2001) *

Age *

Sex *

Male

Female

Prefer not to say

Other:

What priority group do you qualify for? *

Vaccines are currently open to priority group 1 and subgroups 2.1 and 2.2. Please see our website for a better breakdown of these priority groups. If you do not fall in one of these priority groups, please sign up for updates on our website.

Age: between 65 and 75 years old

Age: 75 years or older

Hospital staff essential for care of COVID-19 patients and maintaining hospital capacity

Outpatient clinic staff essential for care of COVID-19 patients and maintaining hospital capacity

Long-term care facility staff

Home care providers for adults 65 years of age and older or high-risk individuals

Emergency Medical Services (EMS)

Outpatient and inpatient medical staff not already included above who are unable to telework

Dentists, dental hygienists and dental assistants

Pharmacists, pharmacy technicians and pharmacy aides

Public health and emergency management response workers who are unable to telework

First responders (other than EMS)

Pre-K–12 school staff and teachers and daycare [childcare] workers

Correctional and detention facility staff (other than medical)

Is it okay for SCPHD to share your contact information with another vaccine provider if they have appointment openings?

Yes

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What is your ethnicity? *

White (not Hispanic or Latino)

Hispanic, Latino, or LatinX

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

American Indian or Native American

Choose not to specify

Thank you!

Please remember, this form is to sign up on a vaccine waitlist. We will contact you as soon as we have an appointment available.

Please monitor your phone for updates. Because Idaho has a very limited supply of vaccine, it may take several weeks to work through your entire priority group.

Learn more about COVID-19 case rates, risk levels, and public heath efforts in this region at phd5.idaho.gov

Idaho has a Vaccine Advisory Committee that has established priority groups who will receive vaccine first. You may find that list here: https://coronavirus.idaho.gov/wp-content/uploads/2020/12/CVAC-Prioritization-for-HCP-and-Essential-Workers.pdf

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