Clatsop County COVID Vaccination Interest Form

If you are interested in receiving a COVID-19 vaccine, you can sign up to be notified when you're eligible. We're asking you about your work, your age and if you have certain health conditions, because that will determine your eligibility based on the State vaccine priority list. Filling out the form does not mean you will automatically receive a vaccine appointment. Vaccine is still limited so even though you may be eligible, it may be several weeks until you are able to schedule an appointment. Completing this form will add you to an outreach list for available vaccine appointments at only the County-sponsored vaccination sites. Once you've signed up, you will receive weekly updates to let you know where we are it in the process, and once you become eligible, we will send you an invitation to schedule a vaccination appointment. You can also sign up on someone's behalf if they don't have access to the internet. People without internet can also receive assistance by contacting the Clatsop County Call Center at 503-325-8500, option #2. Still have a question? Email us at covid19vaccine@clatsopeoc.com

First Name

Last Name*

Age Range*

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Email Address*

If you don't have an email account, answer "none"

Zip Code*

Phone Number*

Are you able to receive text messages?*

If "yes", we'll ask you to provide your cell number in the next question.

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Cell Phone Number

Do you identify as one of the following populations?*

• Asian • Black, African-American, Refugee • Latino/a/x • LGBTQ+ identified individuals • Migrant and seasonal farmworkers • Native, Indigenous, Tribal Members • Pacific Islander • People experiencing behavioral health concerns • People experiencing housing challenges • People with physical, intellectual and developmental disabilities • Recent immigrants • Health care interpreters

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HEALTH & EMPLOYMENT

Where you work and underlying health conditions may impact your vaccine eligibility. Please answer the following questions to assist us in determining how your employment and health status figure into how we prioritize residents according to the State guidelines.

Choose the category that best describes what you do for work. Select "Does Not Apply". If you don't see your work environment listed here, select "Other" and provide additional information in the next question.*

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If you selected "Other" in the previous questions, describe your type of work here.

Medical Conditions & Additional Factors*

Do you have one or more of the following medical conditions that may cause increased risk of severe illness from the virus that causes COVID-19? These include: ▪ Cancer ▪ Chronic Kidney Disease ▪ COPD (Chronic Obstructive Pulmonary disease) ▪ Down Syndrome ▪ Heart Conditions (e.g. heart failure, coronary artery disease or cardiomyopathies) ▪ Weakened immune system from solid organ transplant ▪ Obesity (BMI greater than or equal to 30kg/m2) ▪ Pregnancy ▪ Sickle Cell Disease ▪ Type 2 Diabetes Mellitus ▪ Human immunodeficiency virus (HIV) Additional Factors include: ▪ Likely to develop severe life-threatening illness or death from COVID-19 infection ▪ Acquiring COVID-19 will limit ability to receive ongoing care or services vital to well-being and survival

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ACCESS & FUNCTIONAL NEEDS

The following (optional) questions help us anticipate special needs and to determine how we can best support your vaccination process.

Are you homebound?

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Do you need a ride or transportation to the vaccine clinic?

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Do you require assistance with online registration or accommodations at the vaccine site?

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By checking this box, you attest that the information above is accurate to the best of your knowledge.*

By checking this box, you agree to receive communication (email, text, phone) updates from Clatsop County.*

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