COVID-19 Vaccine Interest Form for Businesses

COVID-19 Vaccine Interest Form for Businesses
The Lenawee County Health Department has begun vaccinating individuals against COVID-19 based on the Michigan Department of Health and Human Services priority groups.

Please complete the following form to help us plan for vaccination of essential workers.
Name of Business*
Point of Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Point of Contact

First NameLast Name
Secondary Point of Contact Phone Number
Please enter a valid phone number.
Email
example@example.com
Number of employees (Lenawee County only) *
Estimated number interested in receiving the vaccine*
Please check the box(es) that best describes your industry*

Healthcare and Public HealthLaw Enforcement, Public Safety, First RespondersEducation (Pre-K through high school teachers, support staff and child care workers)Food and AgricultureEnergyWater and WastewaterTransportation and LogisticsPublic Works and Infrastructure Support ServicesCommunications and Information TechnologyEssential Community or Government Operations and Essential FunctionsCritical ManufacturingHazardous MaterialsFinancial ServicesChemicalDefense Industrial BaseCorrectionsUS postal serviceHomeless SheltersCongregate Child Care InstitutionsAdult and Child Protective ServicesLabsFuneral and Mortuary ServicesNone of the above
Is there anything else we need to know?

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