COVID-19 Business Vaccination Survey

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* 1. Do you wish to schedule a COVID-19 vaccine appointment for your employees with Mahoning County Public Health?

Yes

No

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* 2. Please provide some information about your business:

Name

Address

City

Zipcode

State

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* 3. Do you have more than 5 employees that are willing to get COVID-19 vaccine?

Yes

No

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* 4. How many employees at your agency are interested in getting the COVID-19 vaccine?

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* 5. Please provide the information about the individual who would be responsible to coordinate with the Mahoning County Public Health to schedule the COVID-19 vaccine for your business.

Name

Phone Number

Email