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Online Form to Register for COVID-19 Vaccine

  1. Please Note:

    Completion of this form is optional and voluntary. Completion of this form does not guarantee an appointment for vaccination at this time, but provides a method for Bayfield County Public Health to contact you when vaccine is available in our community. All forms will be reviewed by a Public Health professional and prioritized based on their assessments. Your submission will be kept on file and you will be contacted as soon as appointments are available. Please do not need to call to follow up as we are experiencing high call volume.

  2. Because the U.S. supply of COVID-19 vaccine is expected to be limited at first, CDC is providing recommendations to federal, state, and local governments about who should be vaccinated first. CDC’s recommendations are based on those from the Advisory Committee on Immunization Practices (ACIP), an independent panel of medical and public health experts. For more information on the prioritization schedule for COVID-19 vaccination, please go to: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html

  3. Please do not register your interest (at this time) if you:

  4. • Have had any other vaccination within the past 14 days.

  5. • Recently traveled out of the region or attended a large gathering. Please self-quarantine for 14 days prior to your appointment.

  6. • Are receiving a therapy for any medical conditions. Please consult with your doctor prior to registering your interest.

  7. • Are in isolation or quarantine. Please complete quarantine/isolation and then you may register your interest.

  8. Filling out this form should take about 2 minutes, and the information you enter will be kept private with the Bayfield County Health Department.

  9. Personal Information

  10. Additional Optional Personal Information

  11. Are you a healthcare worker?

  12. Do you volunteer in the healthcare field or in a healthcare setting?

  13. Are you a paid or unpaid personal home care worker?

  14. Do you volunteer with Fire or EMS?

  15. Are you an essential worker?

  16. Are you a member of the clergy?

  17. Retired?

  18. Leave This Blank:

  19. This field is not part of the form submission.