COVID Vaccine Employer Interest Form - Future Eligible Groups

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.

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* 1. Name of Business/Organization

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* 2. Name of Point of Contact

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* 3. Email Address of Point of Contact

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* 4. Phone Number of Point of Contact

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* 5. Category/Type of Business/Organization

Childcare

Congregate Living

Education

Food Service

Grocery Store

Manufacturing

Transportation

Other (specify)

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* 6. Specify "Other" answer above

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

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

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

Yes