Healthcare Worker Vaccine Registration

PLEASE NOTE: This form is not for the general public. Public vaccination will occur at a later date following Pennsylvania Department of Health (PA DOH) guidelines. There is no timeline for public vaccination.

Phase 1A

Healthcare Personnel: Phase 1A: “Health care personnel” are defined by ACIP as paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials. These health care personnel may include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, direct support professionals, clinical personnel in school settings or correctional facilities, contractual staff not employed by the health care facility, and persons (e.g., clerical, dietary, environmental services, laundry, security, maintenance, engineering and facilities management, administrative, billing, and volunteer personnel) not directly involved in patient care but potentially exposed to infectious agents that can be transmitted among from healthcare personnel and patients. “Healthcare settings” refers to the CDC definition of the places where healthcare is delivered and includes, but is not limited to, acute care facilities, long term care facilities, inpatient rehabilitation facilities, nursing home and assisted living facilities, home healthcare, vehicles where healthcare is delivered (e.g., mobile clinics), and outpatient facilities, such as dialysis centers, physician offices, adult day facilities and others.

Healthcare workers not employed by Evangelical Community Hospital but qualifying as Phase 1A and 
seeking COVID-19 vaccination are required to submit this form to register for vaccine distribution. 

Vaccine Distribution and Location

Organizations/individuals will be assigned times for vaccination. Vaccination will occur at various times to best accommodate clinical schedules. Location of the vaccination clinic will be communicated to the contact person indicated on the registration form. 

Vaccination Timeline

PA DOH has not released a timeline for vaccine distribution. Vaccine distribution will be scheduled following notification from PA DOH of delivery of vaccines. 

What to Expect at Vaccination Clinics

Upon arrival, each person will:

  • Sign in and show ID
  • Read and sign a consent form
  • Receive the first dose via a shot
  • Schedule a time to receive the second dose
  • Receive a vaccination card which will need to be saved and brought back for their second dose

The appointment will take approximately 30 minutes (15 minutes for registration and vaccination and 15 minutes for required observation post-vaccine).

Wait List

Registrations will be scheduled in the order they are received. If Evangelical receives more registrations than vaccine doses, a wait list will be established.

Centers for Disease Control and Prevention (CDC) COVID-19 Vaccine Resource

Department of Health (DOH) COVID-19 Vaccine Resource


Vaccine Registration Form

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