COVID-19 Vaccination Survey




Step 1: Select your eligibility

Below are the eligible categories to receive COVID-19 vaccine. Select an option within the category that best describes your eligibility.

Health care workers

Emergency responders

Residents of long-term care facilities

People 65 years of age or older

Other

Education and Childcare

Individuals Enrolled in Medicaid Long-Term Care Programs

Public-Facing Essential Workers

Non-Frontline Essential Health Care Personnel

Congregate Living Facility Staff and Residents

Eligibility groups will change regularly as determined by the State of Wisconsin. If you do not fit into one of the above categories, please check back soon as new eligible groups will be opening up.

Learn more about future eligible groups from the Wisconsin Department of Health Services website here.




Step 2: Who is your employer or to what organization do you belong?


Please select the employment status that best describes you:




Step 3: Your personal information

I hereby attest, to the best of my knowledge, that I am currently eligible to receive the COVID-19 vaccine as determined by guidelines set forth by the Wisconsin Department of Health Services.