COVID-19 Vaccine Interest Form for Businesses
The County Health Department has begun vaccinating essential workers against COVID-19. Please complete the following form for your business to help us plan for vaccination of prioritized groups.
Business Name
Contact Person Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Employee
county specific
Estimated number interested in receiving the vaccine
Industry
Healthcare and Public Health
Law Enforcement, Public Safety, First Responders
Education
Food and Agriculture
Energy
Water and Wastewater
Transportation and Logistics
Public Works and Infrastructure Support Services
Communications and Information Technology
Essential Community or Government Operations and Essential Functions
Critical Manufacturing
Hazardous Materials
Financial Services
Chemical
Defense Industrial Base
Corections
US Postal Service
Homeless Shelters
Congregate Child Care Institutions
Adult and Child Protective Services
Labs
Funeral and Mortuary Services
Other
Comments & Further Information
Submit
Should be Empty: