ECDOH COVID-19 Vaccine Notification Form

Instructions:

This form is for agencies and individuals living in Erie County, NY only. 

FIRST, CLICK HERE to find out if you qualify for vaccination and where to be vaccinated. 


If you qualify, then please complete and submit this form. This form will be used to notify those who qualify about vaccine appointment availability.   

The demand for vaccine currently is much larger than the available supply. It may be weeks or months before you receive a notification. 

  • Hospital staff: contact your hospital to be vaccinated.
  • Federally Qualified Health Center staff: contact your health center to be vaccinated. 
Phase 1 A Vaccine Group that you fall under
Phase 1 B Vaccine Group that you fall under
First Name
Address
Business Name (if applicable)