Garfield County COVID-19 Vaccination Agency Request Information

Garfield County COVID-19 Vaccination Agency Request Information

To help Garfield County Public Health with the rollout of vaccinations for 1B agencies please fill out this form, make sure to include information on all qualifying staff.
Agency Name *
Agency Type *
Agency Point of Contact *

First Name Last Name
Agency Point of Contact Phone *
Please enter a valid phone number.
Agency Point of Contact Email
example@example.com
Number of Qualifying Staff *
Please fill out a line for each qualifying staff person, + to add a new line. This should match the number of qualifying staff. *
If Home Health, please briefly describe the actual services you perform:
Should be Empty: