This survey is intended for businesses who are eligible for vaccination in phase 1b. Only those who live, work, or study in Jefferson County are eligible to take this survey.

Note that taking this survey does not guarantee vaccination. Upon review of survey results, you will be contacted regarding scheduling appointment(s) for vaccination.

Please contact vaccine@jeffersoncountywi.gov with any questions. 

You may find detail on phase 1b eligibility here: https://www.dhs.wisconsin.gov/covid-19/vaccine-about.htm  

Thank you - we look forward to serving you!

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* 1. Are you an organization or employer with employees eligible under Phase 1b criteria for COVID-19 vaccine? See details on eligibility here.

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* 2. Which phase 1b eligible group do you or your organization fall into?

Find details on eligible populations here
https://www.dhs.wisconsin.gov/covid-19/vaccine-about.htm

If you remain unsure of your eligibility, email vaccine@jeffersoncountywi.gov.

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* 3. What is the name of your organization or business?

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* 4. How many individuals eligible for COVID-19 vaccine in phase 1b are employed by your organization?  

Individuals should write the number '1' as their response. 

Note that not all employees of an organization may be eligible in phase 1b for vaccination. Please review the eligibility criteria here.

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* 5. List the number of individuals in your organization who are eligible for vaccine in phase 1b who are also 16 or 17 years of age. There may be age-based restrictions for certain vaccines.  

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* 6. Does your organization desire scheduling of your employee vaccination of phase 1b individuals on different days (staggered) to ensure continuity of operations?

This information may be vital to ensure continuity of operations for your organization in the event that a large percentage of your workforce experiences normal, systemic responses to the vaccine.

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* 7. Will your organization desire on-site vaccination for individuals eligible in phase 1b?

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* 8. Please provide your contact information.

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