Health Department of Northwest Michigan: COVID-19 Vaccine Pre-Registration Survey

COVID-19 Vaccine Pre-Registration Survey
This is a COVID-19 Pre-Registration Survey. If you have already completed a survey for pre-registration, please still complete this survey as it will allow us to update our database and ensure we are vaccinating everyone in a timely manner. If you have already pre-registered to receive the COVID-19 vaccine through the Health Department of Northwest Michigan, the date of your initial pre-registration will be maintained. We will use the information provided in this survey to update our records.

Please note that if you are filling out this survey for a family member or friend, complete the form with the family member/friend’s name, their date of birth, and their residence. Please use the preferred phone and email contact information for scheduling.

If you are registering as an individual, please fill out a new survey for each person you are pre-registering for the COVID-19 Vaccination.

If you are a Business and have employees that fall into multiple priority categories, please fill out a new survey for each priority category you are pre-registering for the COVID-19 Vaccination.

By completing and submitting this survey, I am acknowledging that I agree the information I provide will be utilized for the purpose of scheduling a COVID vaccination appointment through the health department and/or other assisting partners.
Are you registering as an individual or as an employer/business? *

Individual Employer/business entity
Name *

First Name Middle Initial Last Name
Date of Birth *

Month Day Year
Zipcode *
County of Residence *

Antrim Charlevoix Emmet Otsego Other
Telephone Number *
Please enter a valid phone number.
Do you have a smart phone/phone with internet access? *

Yes No
Enter cell phone number here: *
Please enter a valid cell phone number.
Email Address (Please enter twice) *

Confirmation Email example@example.com
Have you already received your first COVID-19 vaccine? *

Yes No
Which counties would you be able to travel to for a COVID Immunization Clinic – select all that apply *

Antrim Charlevoix Emmet Otsego
Do you need assistance in order to get your vaccine at a community clinic? *

No, I can drive myself or have transportation Yes, I need assistance with arranging transportation Yes, I need a wheelchair when I arrive I am concerned that I will not be able to attend a community clinic or won’t be able to get out of my car
Are you 65 years of age or older? *

Yes No
What COVID-19 vaccine priority group do you fall into? *

Paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials and are unable to work from home as well as residents in long-term care facilities Pre-K through grade 12 school staff First responders not included in the options above including firefighters, police, conservation officers, inspectors Corrections workers Childcare workers in a licensed childcare facility Workers in homeless shelters Adult and child protective services workers Funeral Home workers providing mortuary services Members of the clergy who are currently performing (or would like to resume) face to face visitation in homes, long term care facilities or hospitals Employees of County Road commission agencies Frontline Food Processing and Agricultural workers Individuals 50 years of age or older I am a caregiver family member or guardian of a child or adult who has special health care needs Other frontline essential workers in sectors essential to the functioning of society and are at substantially higher risk of exposure due to work duties having to be performed on site and involved being in close proximity to the public or co-workers Individuals age 16 or older at high risk of severe illness due to a chronic medical condition General population: All individuals 16 and older not in earlier priority groups
What type of Frontline Food Processing/ Agricultural worker are you? *

Food processing workers including especially meat processing and meatpacking facilities; processing of fruit and vegetables; dairy processing; animal feed manufacturing; food and animal feed ingredient manufacturing; beverage production; and the production of food packaging. Farmers and farm workers, including migrant and seasonal workers, involved in raising, cultivating, harvesting, packing, storing, and distributing agricultural commodities, and who are by the nature of their work in close proximity and contact with other people. Other Food and Agricultural workers
Please specify other food/agricultural work: *

Restaurant worker Other
Please specify other frontline essential work: *

Other county employee Critical manufacturing worker Public transit worker Grocery store worker US Postal Service worker Restaurant worker
You indicated that you were 50 years of age or older. Which of the following is most applicable to you? *

I have medical conditions or disabilities I live in a congregate care setting/homeless shelter All other individuals 50 years of age or older
You indicated that you were 16 years of age or older in the general population. Which of the following is most applicable to you? *

All other individuals 16 years of age or older
Name of business/organization: *
Name of person completing form: *

First Name Middle Initial Last Name
Title of person completing form: *
Phone number of person completing form: *
Please enter a valid phone number.
Email address of person completing the form (please enter twice): *

Confirmation Email example@example.com
Do you have a smart phone/phone with internet access? *

Yes No
Please enter your cell phone number: *
Please enter a valid phone number.
Zip Code for main office location: *
Postal / Zip Code
County for main office location: *
Counties in which your business has additional offices. Select all that apply (if applicable): *

Antrim Charlevoix Emmet Otsego Other
Number of employees interested in receiving the COVID-19 vaccine: *
What COVID-19 vaccine priority group do your employees fall into? *

Paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials and are unable to work from home as well as residents in long-term care facilities Pre-K through grade 12 school staff First responders not included in the options above including firefighters, police, conservation officers, inspectors Corrections workers Childcare workers in a licensed childcare facility Workers in homeless shelters Adult and child protective services workers Funeral Home workers providing mortuary services Members of the clergy who are currently performing (or would like to resume) face to face visitation in homes, long term care facilities or hospitals Employees of County Road commission agencies Frontline Food Processing and Agricultural workers Other frontline essential workers in sectors essential to the functioning of society and are at substantially higher risk of exposure due to work duties having to be performed on site and involved being in close proximity to the public or co-workers Individuals age 16 or older at high risk of severe illness due to a chronic medical condition General population: All individuals 16 and older not in earlier priority groups
What type of Frontline Food Processing/ Agricultural workers do you employ? *

Food processing workers including especially meat processing and meatpacking facilities; processing of fruit and vegetables; dairy processing; animal feed manufacturing; food and animal feed ingredient manufacturing; beverage production; and the production of food packaging. Farmers and farm workers, including migrant and seasonal workers, involved in raising, cultivating, harvesting, packing, storing, and distributing agricultural commodities, and who are by the nature of their work in close proximity and contact with other people. Other Food and Agricultural workers
Please specify other food/agricultural work: *

Restaurant worker Other
Please specify other frontline essential work: *

Other county employees Critical manufacturing workers Public transit workers Grocery store workers US Postal Service workers Restaurant worker
I certify by completing the pre-registration survey that I am eligible for vaccination in the category I have indicated. (Please check the box to the left and initial below) * Initial here*
Please verify that you are human *
Should be Empty: