Phase 1a and 1b, Group 1 Attestation Form

Once you have completed this form, you will receive a phone call when and if we have a vaccine dose available for you. Vaccine supply remains extremely limited and we do not have enough doses to meet the demand. It could be several weeks before we are able to get back to you, but your information has been collected and you do not need to fill out this form again.

This form is for first dose appointments only. If you would like to schedule a second dose appointment, please visit our second dose page and complete the form.

Which priority phase of the Oregon Health Authority's vaccination rollout plan do you qualify for? Ex. Phase 1a - health care workers, first responders, etc. Phase 1b, Group 1 - K-12 educators, childcare providers, early learning. If you're 65+ years old, click here to use this form.

By checking this box, you are attesting to being a resident of the state of Oregon. 
Please explain how you're qualified for this vaccination priority group?
Categories for Phase 1a

I am attesting to being a part of Phase 1a Group outlined by the Oregon Health Authority for receiving the COVID-19 vaccine. 

  • Group 1: hospitals; urgent care; skilled nursing and memory care facility HCP and residents; tribal health programs; EMS providers and other first responders
  • Group 2: other LTCFs and congregate care sites including HCP and residents; hospice programs; mobile crisis care and related services; secure transport; individuals working in a correctional setting
  • Group 3: outpatient settings serving specific high-risk groups; in home care; day treatment services; non-emergency medical transport (NEMT)
  • Group 4: HCP in other outpatient, public health and early learning settings; death care workers
Categories for Phase 1b

I am attesting to being a part of Phase 1b Group outlined by the Oregon Health Authority for receiving the COVID-19 vaccine. 

  • Group 1: Childcare providers, early learning and K-12 educators and staff.