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* 1. Name of Sector

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* 2. Name of Entity/Company

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* 3. Address of Facility

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* 4. Contact name of person who will be coordinating COVID-19 vaccinations at workplace (AKA - vaccine coordinator)

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* 5. Email for workplace vaccine coordinator

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* 6. Telephone number for workplace vaccine coordinator

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* 7. Vaccinator (business entity giving the shots)

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* 8. Vaccinator point of contact name

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* 9. Vaccinator point of contact email

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* 10. Vaccinator point of contact phone number

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* 11. Number of employees eligible for phase 1b early vaccination (e.g., employees who play a key role in keeping essential functions of society running and cannot socially distance in the workplace)

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* 12. Number of employees eligible for phase 2 (e.g., employees who did not get the vaccine during Phase 1b)

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