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)

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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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* 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.

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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:

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