Vaccine Interest Form

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.

Name* This field is required.

First Name

Last Name

Suffix

Date of Birth* This field is required.

Date

What age are you?* This field is required.

Under 16 years old

16-17 years old

18-64 years old

65+ years old

Do you live in the state of Missouri?* This field is required.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.

YESNO

The zip code where you live* This field is required.

#####

What city do you live in?* This field is required.

Liberty

Kansas City

Gladstone

Kearney

Excelsior Springs

Smithville

North Kansas City

Pleasant Valley

Holt

Missouri City

Mosby

Claycomo

Randolph

Not Applicable - I only work in Clay County, I do not live here.

Are you of Hispanic, Latino or Spanish origin (ethnicitiy)?

Yes

Prefer not to answer

How would you describe yourself?

White/Caucasian

Asian

Black/African-American

Native Hawaiian/Pacific Islander

Prefer not to answer

Do you already know what phase/tier of vaccination you might fall into?* This field is required.It's okay if not! You can learn more about who falls into each phase at covidvaccine.mo.gov/priority.

Phase 1A

Phase 1B - Tier 1

Phase 1B - Tier 2

Phase 1B - Tier 3

Phase 2

Phase 3

I do not know

Are you a paid or unpaid worker in a health care setting?* This field is required.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.

YESNO

Do you work as a first responder or part of emergency services or public health?* This field is required.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.

YESNO

Do you have a health condition that would put you at high risk for severe illness?* This field is required.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.

YESNO

Is your job a part of any of these industries?* This field is required.Click here for the full descriptions.

Education (K-12)

Higher Education

Childcare

Communications Infrastructure

Dams Sector

Energy Sector

Food & Agriculture (Sector 1)

Food & Agriculture (Non-Sector 1)

Government

Elected Official

Information Technology

Nuclear Reactors/Materials/Waste Sector

Transportation Systems Sector

Water/Wastewater Systems

Chemical Sector

Commercial Facilities Sector

Defense Industrial Base Sector

Financial Services Sector

No, I do not work for any of these industries.

Please provide the name of your employerNot required

What is your job title/role?Not required

What transportation is available to you?* This field is required.How easily would you be able to get to a clinic?

I can drive and/or am able to get a ride wherever I need.

I only use public transportation.

None of the above.

Home Phone Number* This field is required.

(###) ###-####

Cell Phone NumberA number that you are able to receive text messages through

(###) ###-####

I consent to receive notifications to my phone regarding COVID-19 vaccination availability and clinic opportunities based on my assigned tier group.* This field is required.

YESNO

Email Address* This field is required.You MUST provide an email address to be alerted to vaccine availability via email.

example@example.com

I consent to receive email notifications regarding COVID-19 vaccination availability and clinic opportunities based on my assigned tier group.* This field is required.

YESNO

I consent to share my name, contact information, and tier status with vaccine providers other than Operation Safe in order to receive the vaccine when it becomes available.

YESNO

Vaccine Interest Form