COVID-19 Vaccine - Phase 1B Resident Contact Form

Contact Information

First Name: (Required)

Last Name: (Required)

Email Address: (Required)

Phone: (Required)

Street Address: (Required)

City: (Required)

This contact form is intended for residents of Cass County, ND. If you live outside of Cass County, ND, please contact the local public health department in your county.

County (Required):

State (Required):

Zip: (Required)

Age / Health

Age Group: (Required)

How many high risk medical conditions apply to you:

Additional Factors

Do you work at or live in a congregate living facility (e.g. corrections facilities, group homes, treatment centers, homeless shelters, etc.)?

Do you work in child care, other than preschool or K-12 education?

Are you a worker employed by preschool or K-12? (teachers, nutritional services, aides, bus drivers, principals, administrative staff, custodians, etc.)