COVID-19 Vaccine Registration Form

At this time, the Pennsylvania Department of Health has asked vaccine providers to prioritize vaccination of healthcare personnel who meet the definition of Phase 1A healthcare personnel in the PADOH Interim COVID-19 Vaccination Plan.

  • "Healthcare personnel" are defined by ACIP as paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials. These healthcare personnel may include, but are not limited to, emergency medical services 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 healthcare 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 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.

If you meet the Department of Health’s definition of healthcare personnel and can provide proof at vaccine registration, then please complete the following demographic information to register your interest in receiving the COVID-19 vaccine at a Penn Medicine Lancaster General Health location.

Please note the required information in the form. If the required information is missing, it may delay or limit your eligibility for the vaccine in this phase.

Thank you!

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