Thank you for taking the time to provide the local health department with your facility's most current information.  


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* Filling out this intake form does NOT guarantee employees in your organization will have access to a vaccination before it is available to the general public.  Determining the allocation of vaccinations will be made by each local health department in accordance with both federal and state guidelines.

Instructions:
  1. This survey should be filled out by all employers that would like their employees to be considered for essential worker vaccination.
  2. Employers with multiple locations should fill out a separate survey for EACH of their facilities/campuses in West Michigan.
  3. Your local health department will follow up with the contact person listed with additional information on vaccination as it becomes available.

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* Company Information - Responses will be kept confidential

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* County

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* Which one of the following best describes your organization’s primary industry?

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* Please provide the information for the person who will serve as the vaccine coordinator between your company and the health department.

Based on the recently updated CISA critical infrastructure definitions, indicate if you have critical workers in the following roles at this facility.

Click the link for a full list of infrastructure definitions. https://www.cisa.gov/sites/default/files/publications/ECIW_4.0_Guidance_on_Essential_Critical_Infrastructure_Workers_Final3_508_0.pdf

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* Critical Manufacturing

Workers manufacturing or providing parts and equipment that enable the maintenance and continued operation of essential businesses and facilities. Complete definition can be found on page 20. 

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* Communication and Information Technology

Workers supporting communications systems, information technology, technical support crucial for business continuity and connectivity. Complete definition can be found on pages 17-19. 

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* Chemical

Workers supporting the chemical and industrial gas supply chains. Complete definition can be found on page 21. 

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* Commercial Facilities

Workers who support the supply chain of building materials from production through application and installation. Complete definition can be found on page 22. 

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* Defense Industrial Base

Workers who support the essential services required to meet national security commitments to the federal government and U.S. military. Complete definition can be found on page 22. 

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* Education

Educators and operational staff facilitating preK-12, college, university, career and technical education, and adult education. Complete definition can be found on page 10. 

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* Energy

Workers supporting the energy sector regardless of the energy source. Complete definition can be found on pages 12- 14. 

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* Financial Services

Workers who are needed to provide, process, and maintain systems for financial transactions and services. Complete definition can be found on page 21.

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* Food & Agriculture

Workers engaged in the manufacture and maintenance of food and beverage supply for humans and animals. Complete definition can be found on pages 10-11.

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* Hazardous Materials

Workers who manage hazardous materials associated with any other essential activity. Complete definition can be found on page 20.

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* Healthcare & Public Health

Including but not limited to supporting access to healthcare and associated functions. Complete definition can be found on pages 7-9.

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* Hygiene and Products and Services

Workers providing personal and household goods, repair, and maintenance. Complete definition can be found on page 23 in the link above. 

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* Law Enforcement, Public Safety, and Other First Responders

Personnel involved in the provisioning of access to emergency services. Complete definition can be found on page 9.

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* Public Works and Infrastructure Support Services

Workers who support the construction, maintenance, or rehabilitation of critical infrastructure. Complete definition can be found on page 17.

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* Residential / Shelter Facilities, Housing and Real Estate, and Related Services

Workers who support food, shelter, and social services, and other necessities of life for needy groups and individuals, including in-need populations and COVID-19 responders. Complete definition can be found on page 23.

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* Transportation and Logistics

Workers supporting or enabling transportation and logistics functions. Complete definition can be found on pages 15-16.

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* Water / Wastewater Systems

Workers needed to operate and maintain drinking water and wastewater and drainage infrastructure. Complete definition can be found on page 15.

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* Other Community or Government Based Operations and Essential Functions

Workers providing dependent care services and other service providers.  Complete definition can be found on pages 19-20.

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* What is your total employee count for this facility?

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* How many essential workers do you employ at this facility?
*An essential worker is an employee whose work-related duties must be performed on-site and involve being in proximity (i.e., within 6 feet) to the public or to coworkers.

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* Please check all on-site health care capabilities that your company currently provides.

  Yes No
 Onsite Health Clinic
Staff Nurse
Other qualified personnel to administer vaccinations (EMT certified, LPN, or volunteers)

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* Is there any other information we should know about your organization as we make plans for essential worker vaccination?

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