1B GROUP

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Promise Community Health Center understands that many want to receive the vaccine. Please be patient as we work through distribution. We will continue to update our communities through social media and our website as new information is available.

If you are in Phase 1B, (listed below) please fill out the form below to be added to our waiting list. If you are not in Phase 1B, please DO NOT fill out the form at this time.

Phase 1B: Priority Group Includes:

Persons aged 65 years and over.
OR, the following populations vulnerable to high risk of exposure or severity of illness (listed in order of priority):

Tier 1
• First Responders
• PK-12 staff, early childhood education, childcare workers

Tier 2
• Frontline essential workers in food, agriculture, and manufacturing sectors who live or work in non-social distanced settings
• Individuals with disabilities living in home settings and their direct care staff

Tier 3
• Staff and individuals living in congregate settings not covered by previous Phase or Tier
• Government officials, including staff, engaged in business at the State Capitol

Tier 4
• Inspectors responsible for health, life and safety

Tier 5
• Correctional facility staff and individuals incarcerated

UPDATE:

Phase 1B has been amended to include the following: “Persons aged 65 years and over or individuals 64 years of age and younger that are or might be at an increased risk of severe illness from COVID-19 due to medical conditions listed at cdc.gov.”

The following are the conditions per the CDC: Adults of any age with the following conditions are at increased risk of severe illness from the virus that causes COVID-19:

Cancer
Chronic kidney disease
COPD (chronic obstructive pulmonary disease)
Down Syndrome
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Immunocompromised state (weakened immune system) from solid organ transplant
Obesity (body mass index [BMI] of 30 kg/m² or higher but < 40 kg/m²)
Severe Obesity (BMI ≥ 40 kg/m²)
Pregnancy
Sickle cell disease
Smoking
Type 2 diabetes mellitus

FULL NAME*
CELL PHONE NUMBER*
DATE OF BIRTH*
MM slash DD slash YYYY
ARE YOU/HAVE YOU BEEN A PROMISE PATIENT?*
- YES
- NO
FULL ADDRESS, STATE & ZIP
Phase 1B has been amended to include the following: “Persons aged 65 years and over or individuals 64 years of age and younger that are or might be at an increased risk of severe illness from COVID-19 due to medical conditions listed at cdc.gov.”
I AM IN THE PHASE 1B PRIORITY GROUP AS DESIGNATED BY THE STATE OF IOWA*
- I am 65 years and older and am one of the phase 1B tiers
- I am 64 years or youngers and are in one of the phase 1B tiers
- I am 64 years or younger and part of the new amended phase 1B group
WHAT TIER APPLIES TO YOU?
- >65 years old
- First Responder
- PK-12 staff, early childhood education, childcare workers
- Frontline essential workers in food, agriculture, and manufacturing sectors who live or work in non-social distanced settings
- Individuals with disabilities living in home settings and their direct care staff
- Staff and individuals living in congregate settings not covered by previous Phase or Tier
- Government officials, including staff, engaged in business at the State Capitol
- Inspectors responsible for health, life and safety
- Correctional facility staff and individuals incarcerated
WHAT CONDITION(S) APPLIES TO YOU?
- Cancer
- Chronic Kidney Disease
- COPD (chronic obstructive pulmonary disease)
- Down Syndrome
- Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
- Immunocompromised state (weakened immune system) from solid organ transplant
- Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
- Severe Obesity (BMI ≥ 40 kg/m2)
- Pregnancy
- Sickle cell disease
- Smoking
- Type 2 diabetes mellitus

Promise Community Health Center in Sioux Center, Iowa | Sliding fee discount on medical services , sliding fee discount on dental services, sliding fee discount on vision services, sliding fee discount on home births, sliding fee discount on prenatal services | Promise Community Health Center accepts Medicare, and Medicaid.

Please click on the buttons below to read through the COVID-19 Consent Forms and Fact Sheets.

COVID-19 SCREENING AND VACCINE ADMINISTRATION RECORD - ENGLISH

COVID-19 SCREENING AND VACCINE ADMINISTRATION RECORD - SPANISH

EAU FACTS SHEET FOR RECIPIENTS AND CAREGIVERS - ENGLISH

EAU FACTS SHEET FOR RECIPIENTS AND CAREGIVERS - SPANISH

Vaccination plans in Sioux County are dependent on vaccination supply and may be subject to change. While vaccine supply is limited, priority for vaccination will be given to individuals who are the highest risk for negative outcomes of COVID-19. More information about vaccination plans will be available after the Iowa Department of Public Health (IDPH) releases more information about the number of doses that will be available in Sioux County.

We will continue to work with IDPH and other healthcare centers in Sioux County to determine the next steps in COVID-19 vaccine administration.

For the most up-to-date information regarding COVID-19 vaccination plans in Sioux County, refer to www.siouxcovid.org.

33 4th St NW, Sioux Center, IA 51250
Phone: 712-722-1700
Fax: 712-722-1770
Email: care@promisechc.org

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This health center receives HHS funding and has Federal Public Health Service deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.