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Operation Safe COVID-19 Vaccine Interest Form
Operation Safe COVID-19 Vaccine Interest Form
Offering appointments to eligible Missourians at our clinic in North Kansas City
21Questions
COVID-19 Vaccine Interest Form - Operation Safe - Missouri
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    Are you interested in getting vaccinated against COVID-19?

    The information you provide through this form will allow Operation Safe to contact you when an appointment is available for you at our vaccination site in North Kansas City.

    Operation Safe is only administering COVID vaccines to people who live in the state of Missouri and are eligible according to Missouri's current phases of distribution.

    Please note: this is not a registration form for vaccination and does not guarantee an appointment. If you are currently eligible for vaccination according to the State of Missouri, we will contact you as soon as an appointment is available for you. If you are not currently eligible, please complete the form and we will contact you after you become eligible and an appointment is available.

     

     

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    Pick a Date
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    At this time Operation Safe is only vaccinating Missouri residents who meet the state's eligibility requirements. By answering yes, you attest that you are a resident of the State of Missouri. If you do not live in Missouri, you can still complete the form and your responses will be recorded for us to possibly contact you for an appointment in the future, if our requirements change.
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    It's okay if not! You can learn more about who falls into each phase at covidvaccine.mo.gov/priority.
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    This includes working for hospitals, long-term care facilities and residents, including Department of Mental Health (DMH)-operated facilities, home health, hospice, dialysis centers, urgent care, vaccinator staff and administering COVID testing, congregate community healthcare settings, including DMH contracted settings (staff and residents) and adult day cares, EMS and high-risk non-congregate healthcare, including clinics, private physicians, and home care providers. Also incudes all remaining patient-facing healthcare providers, including but not limited to health care workers in emergency shelters, dental offices, school nurses, pharmacies, public health clinics, mental/behavioral health providers, and correctional settings.
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    This includes Public Health Administrators and Staff, Law Enforcement, Fire Services, Corrections, Emergency Management, Public Works, Emergency Services, Morticians, Embalmers. Click here for the full descriptions.
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    This includes cancer, Chronic Kidney Disease, COPD, Heart Conditions, weakened immune system due to organ transplant, severe obesity (BMI >40), pregnancy, Sickle Cell Disease, Type 2 Diabetes Mellitus, or individuals with intellectual and/or developmental disabilities such as Down Syndrome.
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    Click here for the full descriptions.
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    Not required
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    Not required
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    How easily would you be able to get to a clinic?
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    A number that you are able to receive text messages through
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    You MUST provide an email address to be alerted to vaccine availability via email.
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Vaccine Interest Form
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