Logan County Vaccine

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COVID Registration Screening Form

Your Information

Full Name*

Full Name as it appears on license if applicable

Date of Birth*

Email Address*

Work email preferred

Cell Phone Number*

Text enabled if available

Employer or Retired*

Eligibility Criteria

The following groups are currently eligible to register and receive COVID vaccination:

Healthcare workers
Coloradans age 60 years and older
Coloradans age 16-59 years with two or more comorbidities
Agricultural workers
Correctional facility workers
COVID response personnel
Emergency medical service personnel
Firefighters
Funeral services workers
Grocery workers
Long term care facility staff
Long term care residents
Police
Pre-K through grade 12 educators

Please bring verification of eligibility, such as ID with name and date of birth or work ID if applicable. For patient safety reasons, name and date of birth will be verified verbally prior to vaccination.

Do you meet eligibility as defined above?*

Yes No

COVID Registration Screening Form

Your Information

Eligibility Criteria

Occupation or Eligibility Criteria