COVID-19 Vaccination Request

Consent to receive the COVID-19 Vaccination * Required
I agree to receive the COVID-19 Vaccination
NC State is collecting information from faculty and staff who are interested in receiving the COVID-19 vaccine. This information will be submitted to the local health department and/or OhioHealth.

OhioHealth will distribute the vaccine between 1 to 4 PM on Wednesdays and Fridays. Ohio Health will assign times based on openings. The vaccination location will be at the Ohio Health Office building next to the Ohio Health Mansfield main entrance. Employees will receive a text or call at the number they provide indicating the assigned appointment for the vaccine.
Name * Required
First Last
Date of Birth - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Address * Required
Street Address City State ZIP Code
Personal/Cell Phone * Required
Have you tested positive for COVID-19? * Required
- Yes
- No
If you have tested positive, When did you receive the diagnosis? - must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY