For Employers Only
The intent of this form is to capture contact and employee information for businesses interested in COVID-19 vaccine for their employees. This is not intended to capture individuals who want to receive the vaccine. Priority for vaccination will be based on the prioritized populations outlined by the CDC. By submitting your information to this form, there is no guarantee that vaccine will be available to your facility.
By completing this form, you confirm that:
- I represent a business or an organization.
- I want to add employees at my worksite(s) to the COVID-19 vaccine registry for businesses.
- I understand my business will be added to the registry and I will be contacted once vaccine is available to my group.
