Page Header

Community

COVD-19 Vaccine Waitlist

This is a preregistration form for MISSOURI RESIDENTS that must be completed in order to be placed on CCMH’s COVID-19 vaccine waiting list.

Disclaimer: We have a limited number of vaccines at this time. There are no guarantees you will receive the vaccine, even if you have completed this preregistration form. There are also no guarantees on which brand of vaccine you will receive. You will only be called when vaccine is available. Please note, we are following state guidelines, and availability and criteria may change at any given time. For the most up-to-date vaccine information, we advise you to frequently visit www.carrollcountyhospital.org/community/covid-19-vaccinator or call the information line at 660-329-6014.

Current Categories (Phase 1A; Phase 1B-Tier1; Phase 1B-Tier 2):*
Any Adults with Qualifying Health Conditions include:

  • Cancer
  • Chronic Kidney Disease
  • COPD
  • Heart Conditions (such as heart failure, coronary artery disease, cardiomyopathies, high blood pressure or high cholesterol)
  • Weakened immune system due to organ transplant
  • Severe obesity (BMI >40)
  • Pregnancy
  • Sickle Cell Disease
  • Type 2 Diabetes Mellitus
  • Individuals with intellectual and/or developmental disabilities such as Down Syndrome
Additional Categories (Phase 1B-Tier 3; Phase 2; Phase 3), SELECT ALL THAT APPLY:

Food & Agriculture Sectors

This section defines the Food & Agriculture Sectors as described by the Missouri Department of Health and Senior Services priority phases.

Food/Agriculture Sector 1: Employees of certain food production and processing facilities, and related operations, prioritizing mass food production, distribution, transportation, wholesale and retail sales, including grocery and convenience stores where groceries are sold. This category includes but is not limited to:

  • Veterinarians, veterinary assistants and laboratory animal caretakers, veterinary technologists and technicians
  • Workers at fuel ethanol facilities, biodiesel and renewable diesel facilities, and storage facilities
  • Workers enabling the sale of human food, animal food (includes pet food, animal feed, and raw materials and ingredients), pet supply, and beverage products at groceries, pharmacies, convenience stores, and other retail
  • Food manufacturer workers and their supplier workers
  • Farmers, farm and ranch workers, and agribusiness support services
  • Workers and firms supporting the distribution of all human and animal food and beverage and ingredients used in these products, including warehouse workers, vendor-managed inventory controllers, and block chain managers.
  • Transportation workers supporting animal agricultural industries

Food/Agriculture Sector 2: Remaining populations within the sector not included in 1B, including restaurants. This category includes but is not limited to:

  • Restaurant and quick serve food operations, including dark kitchen and food prep centers, carryout, and delivery food workers.
  • Workers supporting the sanitation and pest control of all human and animal food manufacturing processes and operations from wholesale to retail.
  • Workers supporting greenhouses as well as the growth and distribution of plants and associated products for home gardens.
  • Workers in cafeterias used to feed workers, particularly worker populations sheltered against COVID-19 and those designated as essential critical infrastructure workers.
  • Government, private, and non-governmental organizations’ workers essential for food assistance programs (including school lunch programs) and government payments.
  • Workers of companies engaged in the production, storage, transport, and distribution of chemicals and other substances used by the human and agricultural food and agriculture industry, including seeds, pesticides, herbicides, fertilizers, minerals, enrichments, equipment, and other agricultural production aids.
  • Workers who support sawmills and the manufacture and distribution of fiber and forestry products, including, but not limited to timber, paper, and other wood and fiber products, as well as manufacture and distribution of products using agricultural commodities.
  • Workers engaged in the manufacture and maintenance of equipment and other infrastructure necessary for agricultural production and distribution.

Government Sectors

This section defines the Government Sectors as described by the Missouri Department of Health and Senior Services priority phases.

Government Phase 1B-Tier 3: Elected officials in any branch of government at the state, county, and/or municipal levels required for the continuity of government; members of the judiciary at the federal, state, and/or local levels required for the continuity of government; employees designated by the federal government that fall within

Government Phase 2: Other state and local government designated personnel required to provide essential services.

For more detailed listings, go to https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/pdf/so-vaccine-distribution-order.pdf. 

By submitting this form, I am self-certifying that everything I have answered on this form is true and I fall into the phase/tier indicated above.

You will know your form has been submitted when you are redirected to a "Thank You for Your Submission" page. Due to high activity with submissions, you may be required to push submit more than once. If you continue to have issues, you may use our COVID-19 Vaccine Waitlist line at 1-888-488-3577. You do not need to submit your information in both places. Thank you for your patience.