Vaccine Eligibility-Agencies and Employers of Eligible Residents

Vaccine Eligibility-Agencies and Employers of Eligible Residents
Please complete this form for your eligible staff included in the Colorado Vaccine Distribution Plan who are eligible because of their job or employment. Please see the state website for additional information and guidance on which employees are eligible.
Agency/Organization/Business Name
Contact Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Location
Industry
Number of eligible staff (particularly frontline essential staff who currently work in close contact with many people, especially indoors)
Should be Empty: