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Coronavirus Updates

Posted on: December 29, 2020

COVID-19 Vaccine Request Forms

NewsFlash- COVID-19 Vaccine Request Forms

COVID-19 Vaccine Supply

The Abilene-Taylor County Public Health District (ATCPHD) is an approved COVID-19 vaccine provider. Supply is currently limited and vaccine administration is based on state guidance which can be found on the Department of State Health Services website.

DISCLAIMER: Submitting the forms below does not guarantee a person and/or organization vaccine nor does it place individuals in a “queue”. Additionally, repeated submissions and calls inhibits our ability to respond in a timely manner. Please only submit when appropriate and only submit one per person/organization. 

COVID Vaccine PhasesChart via https://www.dshs.state.tx.us/coronavirus/immunize/vaccine.aspx

Phase 1A Organizations:

  • Direct Care: Hospital, Long-Term Care, EMS 9-1-1, Home Health, Outpatient, ER/Urgent Care, Pharmacies, Last Responders, School Nurses
  • Long-Term Care: Residents of Long-Term Care Facilities

If you are in Phase 1A and are requesting your organization receives the vaccine, please complete the spreadsheet for each facility that falls within our jurisdiction (Taylor County). Multiple submissions and calls will cause further delays in scheduling. If you are not within the Phase 1A distribution, you will not be placed on a waiting list nor will you be contacted. We receive many requests and can only respond to those meeting the state guidelines. 

1A Request Form

If Phase 1A applies to you, download the 1A Vaccine Request Form (XLSX) and email the completed form to covidvaccine@abilenetx.gov


Phase 1B Individuals:

Taylor County residents that meet phase 1B criteria can complete the following google form and submit. Only submit one form per person. Multiple submissions and calls will cause further delays in scheduling. Additionally, if you do not qualify for Phase 1A-1B distribution, you will not be placed on a waiting list nor will you be contacted. We receive many requests and can only respond to those meeting state guidelines. 

Phase 1B criteria:

  • You are 65 years of age and older 
  • You are 16 years* and older and have a medical condition which places you at higher risk.
    • *Moderna CANNOT be given to anyone under the age of 18.

1B Request Form

If Phase 1B applies to you, submit your request using this form.

Please Note:

  • If you submitted a phase 1B COVID-19 Vaccination Request Form and did not receive an error message, your submission was successful and you have been added to the list.
  • ATCPHD will call you to schedule an appointment to receive your vaccine when it's available. We do not know when we will receive the next shipment.
  • ATCPHD staff cannot confirm receipt and cannot tell you where you are in line. Repeated calls and submissions will create further delays.
  • If you receive an error message, please try submitting again. If you need assistance, contact the Health Department. If lines are busy, please try again as we are experiencing extremely

    high call volumes.

Waitlist Facts:

  • ATCPHD’s waitlist is not shared with other pharmacies or medical providers
    • Please reach out to your primary care provider and local pharmacies to inquire about their vaccine
  • When the ATCPHD receives vaccine:
    • Eligible individuals on the waitlist will be contacted via phone call
      Priority will be based on the Texas DSHS distribution plan (i.e. healthcare workers, individuals over 65 and/or those will qualifying medical conditions)
    • Individuals on the waitlist will receive a call to schedule an appointment
      ATCPHD will not be accepting walk-ins


Individuos Fase 1B:

Los residentes del condado de Taylor que cumplen con el criterio de la fase 1B pueden llenar la siguiente forma de Google y enviarla. Solamente envié una forma por cada persona. Entradas múltiples o llamadas causaran aún más retrasos para darle una cita. Adicionalmente, si no cumple con el criterio de la fase 1B, no se pondrá en la lista de espera y no se le contactará. Recibimos muchas solicitudes y nomas podemos responder a las que cumplen con las directrices estatales.

Criterios de la fase 1B:

  • Tienes 65 años o más
  • Tiene 16 años *o más y padece al menos de una  condición médica que lo pone en mayor riesgo

* Modern NO SE PUEDE dar a menores de 18 años.

Formulario de solicitud 1B

Si cumple con el criterio de la Fase 1B, envíe su solicitud utilizando este formulario.

Tenga en cuenta:

  • Si envió un Formulario de solicitud de vacunación COVID-19 fase 1B y no recibió un mensaje de error, su envío fue exitoso y ha sido agregado a la lista.
  • ATCPHD lo llamará para programar una cita para recibir su vacuna cuando esté disponible. No sabemos cuándo recibiremos el próximo envío.
  • El personal de ATCPHD no puede confirmar la recepción y no puede decirle dónde se encuentra en la fila. Las llamadas y presentaciones repetidas crearán más demoras.
  • Si recibe un mensaje de error, intente enviarlo nuevamente. Si necesita ayuda, comuníquese con el Departamento de Salud. Si las líneas están ocupadas, inténtelo de nuevo, ya que estamos experimentando altos volúmenes de llamadas.

Waitlist Facts:

  • La lista de espera de ATCPHD no se comparte con otras farmacias o proveedores médicos
    • Comuníquese con su proveedor de atención primaria y las farmacias locales para obtener información sobre su vacuna.
  • Cuando ATCPHD recibe la vacuna:
    • Se contactará a las personas elegibles en la lista de espera por teléfono
      La prioridad se basará en el plan de distribución del DSHS de Texas (es decir, trabajadores de la salud, personas mayores de 65 años y / o quienes tendrán condiciones médicas que califiquen)
    • Las personas en la lista de espera recibirán una llamada para programar una cita.
      ATCPHD no aceptará visitas sin cita previa.

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