Vaccine Interest

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This form is to assess vaccination interest and assist with planning efforts in Leavenworth County, Kansas. At this time, this form is not for scheduling appointments and does not reserve a vaccine for you.

Once the vaccine is available for Phase 2, the Health Department will use your information to contact you with further instructions on scheduling an appointment to receive your vaccination.

Please do not call. Leavenworth County Health Department does not have the capacity to return phone calls regarding your form's status.

Complete this form to let the Leavenworth County Health Department know whether you would like to receive the vaccine as it becomes available for specific phases of the vaccination plan. We will use the contact information to send you vaccine availability and location updates.

Full Name*?

Address*?

Phone Number*?

If you do not have an email address, please leave this field blank.

Email Address*?

Date of Birth*?

Which Phases Two Group Do You Fit? (Examples are provided below)

Phase Two Group:*

Person Aged 65 or Older

Person (employees and residents) in Congregate Settings

High-Contact Critical Workers

All Unvaccinated Persons Prioritized in Previous Phases

Examples of Phase Two Groups are:
Person (employees and residents) in congregate settings, such as:

• Homeless shelters/homeless housing settings.
• Congregate childcare institutions, adult and child protective services.
• Emergency shelters or safe houses for victims of domestic violence.
• Corrections facilities, including jails and juvenile justice facilities.
• Behavioral Health institutions (including mental health institutions) and residential treatment centers.
• Adult care homes, those in home plus facilities not covered in phase 1.
• Senior living homes.
• Personal care aides

High-Contract Critical Workers, such as:

• First responders, correction officers.
• Grocery store workers and food services.
• K-12 and childcare workers.
• Food processing.
• Large-scale aviation manufacturing plants.
• Transportation workers.
• Workers in the following industries, if they regularly need to be in high-risk settings to perform their duties:
  • Retail, warehouses and sales outlets.
  • Agriculture.
  • Supply of critical services or materials for the COVID-19 response.
  • The U.S. Postal Service.
  • Department of Motor Vehicles.