Use this form to submit your business / organization's information surrounding the COVID-19 vaccine and potential eligibility for it under Phase 1B. 

Note: Submitting information using this form DOES NOT guarantee vaccination under Phase 1B, nor does it add your entity or employees to a wait list. The City of Racine Public Health Department will use this information, in conjunction with Phase 1B criteria when released by WI DHS, to assist with matching eligible entities to available vaccinators.

Question Title

* 1. Name of Business/Organization

Question Title

* 2. Name of Point of Contact

Question Title

* 3. Email Address of Point of Contact

Question Title

* 4. Phone Number of Point of Contact

Question Title

* 5. Category/Type of Business/Organization

Question Title

* 6. Specify "Other" answer above

Question Title

* 7. How many employees does your organization/business have that you believe qualify for the COVID-19 vaccine under Phase 1B?

Question Title

* 8. How many employees (out of the above number) does your organization/business have that are interested in receiving the COVID-19 vaccine?

Question Title

* 9. By checking "Yes" below, I attest that the information provided within is accurate to the best of my knowledge.

T