Virus Outbreak Pfizer Vaccine

This file photo shows the first patient enrolled in Pfizer's COVID-19 coronavirus vaccine clinical trial at the University of Maryland School of Medicine in Baltimore. On Monday, Nov. 9, 2020, Pfizer said an early peek at its vaccine data suggests the shots may be 90% effective at preventing COVID-19. (Courtesy of University of Maryland School of Medicine via AP, File)

LAS VEGAS (FOX5) -- The state on Tuesday released a survey for those who want to receive the COVID-19 vaccine.

The survey was posted by the Nevada State Immunization Program for individuals or workplaces.

"Once the form is submitted, the collected information will be shared with the appropriate county jurisdiction. A response and further information will be provided by the county where the individual lives," said Shannon Litz with the Nevada Department of Health and Human Services.

They survey asks for basic information, such as name and contact information, as well as which grouping by age and underlying condition.

To take the survey, click here.

For more information on the state immunization program, click here. To read the latest version of the COVID-19 vaccine playbook, click here.

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