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* 1. What is the name of your company, practice, or department?

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* 2. Street address or PO Box

If your address is "123 Main St, Oshkosh, WI 54901" please enter "123 Main St".

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* 3. City

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* 4. First and Last name of contact person.

e.g. John Smith

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* 5. Phone number

Please format your phone number similar to 920-555-5555

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* 6. Email address

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* 7. County

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* 8. How many staff are at this location total, including those who have not been vaccinated yet.

0 1000
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i We adjusted the number you entered based on the slider’s scale.

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* 9. How many staff at your location qualify for Phase 1A vaccination?

0 1000
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i We adjusted the number you entered based on the slider’s scale.

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* 10. Which of the following job categories does your organization fall under?

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* 11. Please enter any other information you would like Winnebago County Health Department to know that has not already been captured by this survey.

0 of 11 answered
 

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