BCGHD COVID-19 Vaccination Survey

Butler County General Health District is moving COVID vaccine out to the community just as fast as it is coming in. We are following the guidelines established by Governor DeWine and Ohio Department of Health for who is vaccinated in Ohio's Phase 1A and Phase 1B. We have received a limited number of doses so far. We hope to see the numbers increase as manufacturers increase their capacity.

When completing this survey you can register for yourself, another person (a family member/dependent etc.) or on behalf of your company/employer.

The purpose of this survey is to allow Butler County residents and organizations to register their contact information with BCGHD.

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* 1. Are you registering for yourself, another person, or on behalf of an organization? (If you need to register for yourself AND another person, please fill out the survey once for each person)

Organization that Qualifies for Phase 1A

Myself - I Qualify for Phase 1A

Myself - I Qualify for Phase 1B

Someone Else (family member, dependent, etc.) - They Qualify for Phase 1B

Organization that Qualifies for Phase 1B

Myself - I do not qualify for Phase 1 A or B

Organization that does not qualify for Phase 1A or B

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* 2. First Name

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* 3. Last Name

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* 4. Email Address

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* 5. Phone Number

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* 6.
For INDIVIDUALS registering: Please select the category under which you or the person you are registering for qualify for Phase 1 A/B or select "None of the Above"

For ORGANIZATIONS registering: If you are registering on behalf of an organization, please select "Registering on Behalf of An Organization".

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* 7. TO BE COMPLETED BY ORGANIZATIONS REGISTERING AND PHASE 1A INDIVIDUALS ONLY (SKIP QUESTION IF YOU ARE REGISTERING AS AN INDIVIDUAL OUTSIDE OF PHASE 1A): If you are registering on behalf of an Organization Please list your organization information here. If you are an individual registering for Phase 1A, please list your employer information here.

EMPLOYER/ORG.

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 8. TO BE COMPLETED BY ORGANIZATIONS REGISTERING ONLY (SKIP QUESTION IF YOU ARE REGISTERING AS AN INDIVIDUAL): Please describe your organization type (i.e. congregate living, dental office, medical transportation, etc.)

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* 9. TO BE COMPLETED BY ORGANIZATIONS REGISTERING ONLY (SKIP QUESTION IF YOU ARE REGISTERING AS AN INDIVIDUAL):
Please indicate the number of vaccines needed per category:

Staff routinely involved in care of COVID-19 patients

Staff NOT routinely involved in care of COVID-19 patients

Clients/Patients (if applicable)

BCGHD COVID-19 Vaccination Survey

Question Title

* 1. Are you registering for yourself, another person, or on behalf of an organization? (If you need to register for yourself AND another person, please fill out the survey once for each person)

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* 2. First Name

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* 3. Last Name

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* 4. Email Address

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* 5. Phone Number

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* 8. TO BE COMPLETED BY ORGANIZATIONS REGISTERING ONLY (SKIP QUESTION IF YOU ARE REGISTERING AS AN INDIVIDUAL): Please describe your organization type (i.e. congregate living, dental office, medical transportation, etc.)

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* 9. TO BE COMPLETED BY ORGANIZATIONS REGISTERING ONLY (SKIP QUESTION IF YOU ARE REGISTERING AS AN INDIVIDUAL):Please indicate the number of vaccines needed per category:

* 9. TO BE COMPLETED BY ORGANIZATIONS REGISTERING ONLY (SKIP QUESTION IF YOU ARE REGISTERING AS AN INDIVIDUAL):
Please indicate the number of vaccines needed per category: